NR 325 ADULT HEALTH FINAL GUDE.| VERIFIED SOLUTION

NR 325 ADULT HEALTH FINAL GUDE.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.