NR 325 ADULT HEALTH FINAL GUDE.| VERIFIED GUIDE

NR 325 ADULT HEALTH FINAL GUDE.| VERIFIED GUIDE 1. How does the nurse confirm a basal skull fracture when implementing evidence based practice? What is the nurses’ responsibility in each of these diagnosis? Types of skull fractures: linear or depressed, simple, comminuted or compound, open or closed. **Basilar fracture is a a specialized linear fracture involving the base of the skull (breaking of bones at the base of the skull.) Manifestations appear over several hours which include: cranial nerve deficits, Battle’s Sign (postauricular ecchymosis), periorbital ecchymosis (raccoon eyes). Fracture associated with a tear in the dura and leakage of CSF. Rhinorrhea(CSF leakage for the nose) and otorrhea(CSF leakage from the ear), this confirms the fracture has extended into the dura. CSF leakage=high risk meningitis and antibiotics should be given as preventative. Other Manifestations:bulging tympanic membrane caused by blood or CSF, tinnitus/hearing difficulty, facial paralysis, conjugate deviation gaze (both eyes are deviated in the same direction) and vertigo. TWO Diagnostic tests used to determine if CSF is leaking from nose or ear: if there is drainage. 1st: Dextrostix/Tes-Tape stripis used to determine if glucose is present **Remember CSF is loaded with glucose**. (If blood present testing is unreliable because blood also contains glucose. **Look for Halo Sign or Ring Sign**= by allowing the leaking fluid to drip onto white gauze pad or towel and observe drainage. Within minutes, blood moves into the center and a yellowish ring will encircle the blood if CSF is present. Note color appearance and amount of leakage. False positive results could occur. Major potential complications of skull fracture= intracranial infections, hematoma, meningeal and brain tissue damaged. Also note if basilar skull fracture is suspected NG tube or oral gastric tube should be inserted under fluoroscopy. (pg. 1369) Intracranial Pressure Manifestations: (ATI pg. 14)Monitor for these manifestations **listed in Question 21. ** 2. What is the emergency intervention for a conscious client who has a suspected cervical (spinal) cord injury? Identify the differences between Cervical, Thoracic, and Lumbar cord injuries and their treatments associated with each injury. What is the nurses’ responsibility in each of these diagnosis? Acute care of suspected cervical (spinal) cord injury: Immobilize vertebral column, Maintence of heart rate (atropine), and BP (dopamine), Insert NG tube and attach suction. Intubation if needed. O2 administration by high humidity mask, indwelling catheter, administer IV fluids, stress ulcers prophylaxsis. DVT prevention, bowel/bladder training. *C4 injury=Tetraplegia. Above C4 patient will have total loss of respiratory function (Mechanical ventilation required) Below C4 results in diaphramgtic breathing if phrenic nerve is functioning. Nursing intervention=Patient can not cough and remove secretions, pneumonia and atelectasis can develop. *C6 Injury= Partial paralysis of the hands and arms and lower body *T6 Injury=Paraplegia=Paralysis below the chest Any injury above T6, Patient will have bradycardia & periperihal vasodilation=hypotension. *L1 Injury= Paralegia=Paralysis below the waist. Injury above L1/L2 will convert to spastic muscle tone after neuro shock (upper motor neuron injuries).Injury below L1/L2 convert to a flaccid type of paralysis (Lower motor neuron injuries) *Autonomic dysreflexia: ATI pg. 16 Nursing Interventions: encourage active ROM exercises if possible, passive if patient lacks motor functions. Monitor I/O, Maintain fluids to prevent urinary calculi and bladder infections. Prevent skin breakdown, can use special bed and equipment for this. Monitor bowel sounds (ileus could develop). Change position every 2 hours (can not feel pain or prolonged pressure). Teach about sexual functions. Quad patients/upper motor neuron=usually capable of reflexogenic erections (erections secondary to manual manipulation) Ejaculation coordination with emission might not occur. Lower neuron injuries less likely to have reflexogenic erections but might be able to have combo of reflexogenic and psychogenic erections (sexual thoughts/images). Bowel: Use daily stool softeners or bulk-forming laxatives. Bowel movement can be stimulated daily or everyother day by bisacodyl suppository or digital(finger) stimulation. ** Use digital stimulation cautiously to avoid provoking a vagal response, which leads to bradycardia and syncope. Questions 7 lists Bladder interventions. Patient can experience two types of shock: spinal shock: decreased reflexes, loss of sensation and flaccid paralysis below the level of injury, can last days to month and may mask postinjury neurological function. Neurogenic shock: contrast to spinal shock due to the loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and decreased cardiac output. Usually associated with cervical or high thoracic injury. **Nursing interventions for neurogenic shock: Monitor for hypotension, dependent edema, and loss of temperature regulation (common manifestations). When Patient is upright, patient will experience postural hypotension. When transferring a client to a wheelchair: slow and in stages · Raise the head of the bed and be ready to lower the angle if patient gets dizzy. Transfer the client into a reclining wheelchair with back of the wheelchair reclined. Be ready to lock and lean the wheelchair back onto knee to a fully reclining position if the patient reports dizziness after transfer. Do not return patient to the bed · Monitor for manifestations of thrombophlebitis (swelling of extremity, absent/decreased pulses, and areas of warm and tenderness) Patient may need anticoagulants to prevent development of lower extremity thrombi. 3. What are the signs of appendicitis, positive signs, the treatment, pharmacotherapy, and what does a potential rupture, and rupture look like? What are the surgical interventions? What is the nurses’ responsibility in each of these diagnosis? Signs of appendicitis: Abdominal pain in the RLQ, rigid abdomen, decreased or absent bowel sounds, fever, diarrhea/constipation, lethargy, tachycardia, rapid shallow breathing, anorexia, possible vomiting. Positive signs: Abdominal pain that is most intense at McBurney’s point. Rebound tenderness and abdominal rigidity, elevated white blood cell count. Surgical Interventions: Appendectomy Pre-op: **(removal of NONruptured appendix)..Laparoscopic surgery, Administer IV fluid replacement as prescribed, Administer antibiotic. **(removal of Ruptured)..Laparoscopic OR open surgery. Administer electrolyte and fluid replacement as prescribed, place NG tube for decompression, administer antibiotics. Post-op **(NONruptured appendix)..assess respiratory status, maintain airway, provide O2 as prescribed, vitals, administer analgesics for pain, assess surgical site or any abnormalities, assess bowel sounds and bowel function. **(Ruptured appendix) Same as nonruptured PLUS; Maintain NPO status, maintain NG tube to low continuous suction. Provide wound irrigations with antibacterial solution or saline-soaked gauze as prescribed. Provide drain care. Assess for peritonitis (fever, sudden increase in pain, irritability, rigid abdomen, abdominal distention, tachycardia, rapid shallow breathing, pallor, chills. 4. Identify the sign of delirium, dementia, and confusion. Which of these conditions are acute or chronic? What is the nurses’ responsibility in each of these diagnosis? Delirium (Acute, Temporary): state of temporary but acute mental confusion is common, life threatening, and possibly preventable syndrome. Causes: (Also nursing actions apply to treating the problems) Dementia, dehydration Electrolyte imbalances, emotional stress Lung, liver, heart, kidney, brain Infection, intensive care unit Rx drugs Injury, immobility Untreated pain, unfamiliar environment Metabolic disorders Dementia (Chronic, slow progression): syndrome characterized by dysfunction or loss of memory, orientation, attention, language, judgment, and reasoning. Personality changes and behavioral problems such agitation, delusions, and hallucinations may occur. DX when two or more brain functions are significantly impaired such as memory loss, language skills etc. Sleeping during day, and awakening at night. Confusion: Can be acute/chronic, Less extreme than delirium. Slurring words, long pauses in speech, abnormal or incoherent speech, lack of awareness of location or time, forgetting tasks being performed while performing it. Sudden changes in emotion such as sudden agitation. ***Treatment in Question #6*** Dementia (Chronic) Delirium (Acute) Onset Usually Insidious Rapid, often at night Progression Slow Abrupt Duration Years (usually 8-20 years) Hours to days to weeks Thinking Difficulty with abstract thinking, impaired judgment, words difficult to find Disorganized, distorted. Slow oe accelerated incoherent speech. Perception Misperceptions often present. Delusions and hallucinations Distorted. Delusions and hallucinations Pyscho-motor behavior May pace or be hyper active. As disease progresses, may not be able to perform tasks or movements when asked. Variable. Can be hyperactive or hypoactive or mixed. Sleep-wake cycle Sleeps during day. Frequent awakenings at night. Fragmented sleep. Disturbed sleep cycle. Reversed sleep cycle 5. What is the treatment for hypothyroidism, hyperthyroidism, Grave’s disease, Addison disease, Addison Crisis, Cushing Disease, and Myxedema? What are the symptoms for each disease, and how is each disease process treated during and acute phase or emergent phase? Know the difference. Hypothyroidism: S/S: Fatigue, lethargy, intolerance to cold, constipation, weight gain without an increase in caloric intake, pale skin, thick, brittle fingernails, depression and apathy, periorbital edema, joint or muscle pain; bradycardia, hypotension, dysrhythmias, slow thought processes and speech, hypoventilation, pleural effusion, thickening of the skin, thinning of hair on the eyebrows, dry, flaky skin, swelling in face, hands, and feet (myxedema [non-pitting, mucinous edema]), decreased acuity of taste and smell, hoarse, raspy speech, abnormal menstrual periods (menorrhagia/amenorrhea), decreased libido An increased TSH indicates primary hypothyroidism due to thyroid dysfunction or thyroiditis. Treatment: ● Thyroid hormone replacement (e.g., levothyroxine) ○ Nursing considerations ■ Administer thyroid hormone replacement therapy. ■ Monitor for cardiovascular compromise (e.g., chest pain, palpitations, rapid heart rate, shortness of breath). ● Monitor thyroid hormone levels and adjust dosage (if needed) ● Nutritional therapy to promote weight loss ● Patient and caregiver teaching Myxedema (hypothyroidism crisis situation): Myxedema coma is a life-threatening condition that occurs when hypothyroidism is untreated or when a stressor (e.g., acute illness, surgery, chemotherapy, discontinuing thyroid replacement therapy, or use of sedatives/opioids) affects a client who has hypothyroidism. S/S: Respiratory failure; Hypotension; Hypothermia; Bradycardia, dysrhythmia; Hyponatremia; Hypoglycemia; Coma Nursing Considerations: ● Maintain airway patency with ventilatory support if necessary. ● Provide continuous ECG monitoring. ● Monitor ABGs to detect hypoxia, hypercapnia, respiratory acidosis. ● Monitor mental status. ● Cover the client with warm blankets. ● Monitor body temperature hourly until stable. ● Replace fluid with 0.9% sodium chloride IV. ● Replace thyroid hormone by administering large doses of levothyroxine IV bolus. ● Monitor vital signs because rapid correction of hypothyroidism can cause adverse cardiac effects. ● Monitor I&O and daily weights. With treatment, urine output should increase, and body weight should decrease. Failure to do so should be reported to the provider. ● Treat hypoglycemia with glucose. ● Administer corticosteroids. ● Initiate aspiration precautions ● Check for possible sources of infection (blood, sputum, urine) that might have precipitated the coma. Treat any underlying illness. Hyperthyroidism: (Grave’s disease) Graves' disease is exophthalmos, a protrusion of the eyeballs from the orbits that is usually bilateral S/S: nervousness, irritability, hyperactivity, emotional lability, decreased attention span, cries or laughs without cause, change in mental or emotional status, weakness, easy fatigability, exercise intolerance, muscle weakness, heat intolerance, weight change (usually loss) and increased appetite, insomnia and interrupted sleep, frequent stools and diarrhea, menstrual irregularities (amenorrhea or decreased menstrual flow) and decreased fertility, libido initially increased in both men and women, followed by a decrease as the condition progresses, warm, sweaty, flushed skin with velvety-smooth texture, hair thins, and develops a fine, soft, silky texture, tremor, hyperkinesia, hyperreflexia, exophthalmos (graves’ disease only) due to edema in the extraocular muscles and increased fatty tissue behind the eye, blurred or double vision and tiring of eyes due to pressure on the optic nerve, photophobia (sensitivity to light), excessive tearing and bloodshot appearance of eyes, pretibial myxedema: dry waxy swelling of the front surfaces of the lower legs that resembles benign tumors (graves’ disease only), vision changes ( eyelid retraction (lag): movement of the eyelid is delayed when the eye moves downward; globe (eyeball) lag: upper eyelid pulls back faster than the eyeball when the client gazes upward ), hair thinning or loss, goiter, bruit over the thyroid gland, elevated systolic blood pressure and widened pulse pressure, tachycardia, palpitations, and dysrhythmias, dyspnea, findings in older adult clients are often more subtle than those in younger clients (Occasionally, an older adult client who has hyperthyroidism will demonstrate apathy or withdrawal instead of the more typical hypermetabolic state. Older adult clients who have hyperthyroidism often present with heart failure, angina, and atrial fibrillation.) A decreased value indicates hyperthyroidism (graves’ disease) or secondary hypothyroidism (due to pituitary or hypothalamus dysfunction). Treatment: ● Drug Therapy ○ Thionamides are used to treat Graves’ disease, as an adjunct to radioactive iodine therapy, to decrease hormone levels in preparation for surgery, and to treat thyrotoxicosis (ATI p. 507). ■ methimazole (Tapazole) ■ Propylthiouracil ○ Iodine (SSKI) ■ Lugol’s solution is a nonradioactive 5% elemental iodine in 10% potassium iodine that inhibits the release of thyroid hormone. ● β-Adrenergic receptor blockers treat sympathetic nervous system effects (tachycardia, palpitations). These medications counteract the effects of increased thyroid hormones but do not alter the levels of the hormones (ATI p. 507). ○ propranolol (Inderal) ○ atenolol (Tenormin) or metoprolol (Toprol) ● Radiation Therapy ○ Radioactive iodine is taken up by the thyroid and destroys some of the hormone- producing cells (131 I). ■ One dose can be sufficient, but a second or third dose might be needed. ■ The degree of thyroid destruction varies and can require lifelong thyroid replacement. ● Surgical Therapy ○ Subtotal thyroidectomy can be performed for the treatment of hyperthyroidism when medication therapy fails or radiation therapy is contraindicated. It can also be used to correct diffuse goiter and thyroid cancer. After a subtotal thyroidectomy, the remaining thyroid tissue usually supplies enough thyroid hormone for normal function (ATI). ○ Total thyroidectomy is performed, the client will need thyroid hormone replacement therapy. ● Nutritional Therapy ○ High-calorie, high-protein diet ○ Frequent meals Thyroid storm/crisis results from a sudden surge of large amounts of thyroid hormones into the bloodstream, causing an even greater increase in body metabolism. This is a medical emergency with a high mortality rate (ATI). ● Nursing considerations (ATI): ○ Maintain a patent airway. ○ Provide continuous cardiac monitoring for dysrhythmias. ○ Administer acetaminophen to decrease temperature. ! Salicylate antipyretics (aspirin) are contraindicated because they release thyroxine from protein- binding sites and increase free thyroxine levels. ○ Provide cool sponge baths, or apply ice packs to decrease fever. If fever continues, obtain a prescription for a cooling blanket for hyperthermia. ○ Administer thionamides (methimazole or propylthiouracil) to prevent further synthesis and release of thyroid hormones. ○ Administer sodium iodide as prescribed, 1 hr after administering thionamide medication. ○ Administer beta-adrenergic blocking agents, such as propranolol, to block sympathetic nervous system effects. ○ Administer glucocorticoids if adrenal insufficiency is suspected or to treat shock. ○ Administer IV fluids to provide adequate hydration and prevent vascular collapse. Fluid volume deficit can occur due to increased fluid excretion by the kidneys or excessive diaphoresis. Monitor intake and output hourly to prevent fluid overload or inadequate replacement. ○ Administer supplemental O2 to meet increased oxygen demands. System Cushing’s Disease/ Syndrome (too much) Addison's Disease (too little) Glucocorticoids General appearanc e Truncal obesity, thin extremities, rounding of face (moon face), fat deposits on back of neck and shoulders (buffalo hump) (Fig. 49-11). Weight loss, emaciation.