NS 233 exam 2 with 100% correct answers 2023/24

What are the risk factors for getting meningitis (for each type)? Viral: -no vaccine -other viral illnesses i.e. mumps measles,herpes, and west nile Fungal: -caused by cryptococcus neoformans Bacterial: MOST IMPORTANT TO REMEMBER -immunosuppression -invasive procedures, skull fracture, or penetrating head wound (bacteria has direct access to CSF) -overcrowded or communal living conditions (reason why college kids are more likely to get it being in the dorms) What clinical manifestations would be seen in meningitis? -constant headache -nuchal rigidity -photophobia -nystagmus -abnormal eye movements -fever -chills -N&V -altered level of consciousness (confusion, disorientation [person, place and year], lethargy, difficulty arousing, coma -positive Kernig's sign: resistance and pain with extension of the clients leg from a flexed position -positive Brudzinski's sign: flexion of extremities occurring with deliberate flexion of the client's neck) -hyperactive deep tendon reflexes -tachycardia -seizures may occur due to increased intracranial pressure -restlessness, irritability -red macular rash (meningococcal meningitis) What laboratory tests are done for meningitis? -lumbar puncture for CSF analysis (most definitive) -CBC (typically WBC are elevated) -CT or MRI is used if increased intracranial pressure is suspected What type of nursing care can be implemented for those with meningitis? -isolation precautions (droplet and private room) -implement fever reduction measures (i.e. cooling blanket) -report meningococcal infections to the public health department -provide a quiet room and minimize exposure to light -bed rest with head elevated to 30 degrees (and avoid coughing or straining) -monitor the client for increased intracranial pressure (decreased level of consciousness, pupillary changes, impaired extraocular movements) -seizure precautions -replace fluid and electrolytes as indicated by lab values What is a seizure? an abnormal, sudden, excessive, uncontrolled electrical discharge of neurons within the brain that may result in a change in LOC, motor and sensory ability, and/or behavior (some may be caused by pathological conditions of the brain) What is epilepsy? two or more seizures experienced by a person, it is a chronic disorder in which repeated unprovoked seizure activity occurs ( it may be caused by an abnormality in electrical neuronal activity; imbalance of neurotransmitters [especially GABA], or combination of both) What is a generalized seizure (describe each type). Involves both hemispheres Tonic-clonic seizure: -lasts 2-5 minutes -tonic phase: stiffening or rigidity of muscles (particularly arms and legs) and immediate loss of consciousness -clonic phase: rhythmic jerking of all extremities (may bite tongue and become incontinent -fatigue, acute confusion and lethargy Absence: -most common in children -loss of consciousness lasting a few seconds -associated with blank staring -may include unconscious, involuntary behavior associated with eye fluttering, smacking of lips and picking at clothes called automatisms -patient is not aware of these behaviors or that it is happening Myoclonic: -consist of brief jerking or stiffening of extremities (can by asymmetrical or symmetrical) -can last for seconds Atonic (akinetic) -few seconds in which muscle tone is lost -followed by a period of confusion -loss of muscle tone frequently results in falling What is partial seizure and describe each type. Involves one cerebral hemisphere Complex: -associated automatisms (behaviors that the client is unaware of, such as lip smacking or picking at clothes) -can cause loss of consciousness for several minutes -amnesia may occur immediately prior to and after the seizure Simple: -consciousness is maintained throughout -may consist of unusual sensations, a sense of déjà vu, autonomic abnormalities (changes in HR, abnormal flushing, epigastric discomfort), unilateral abnormal extremity movements, pain or offensive smell What is an unclassified or idiopathic seizure? Does not fit into a category, it occurs for no reason (accounts for half of all seizure activities). What are secondary seizures? They result from an underlying brain lesion, usually a tumor or trauma (tx is the removal or tx of the underlying condition or cause) What diagnostic tests are used for seizures? -EEG -CT scan -MRI -PET scan -lab studies are used to find metabolic or other disorders/imbalances What are common side effects of seizure medications? liver impairment, fatigue, dizziness, and drowsiness What seizure precautions should be taken in each patients room? -suctioning -oxygen -if patient does not have IV access insert a saline lock (provides easy access for IV drug therapy to be given to stop seizure) -bed in the lowest position and padding on the side rails to prevent injury What should be done for a patient during a seizure? -remove anything that can cause injury, clutter, etc. -position client to provide a patent airway -prepare to suction -turn client to side -loosen restrictive clothing -do NOT restrain client -do NOT put anything in their mouth -document onset, duration, client finding/observations prior to, during, and following the seizure (i.e. LOC, apnea, cyanosis, motor activity, incontinence) What should be done after the patient experiences a seizure? -maintain patient in side lying position -VS -assess for injury -neurological checks -allow client to rest if necessary -reorient and calm client as they may be agitated or confused -determine if the patient experienced an aura -try to figure our a possible trigger Describe status epilepticus. Prolonged seizure activity occurring over a 30 minutes time frame (seizure lasting longer that 5 minutes or repeated seizures over the course of 30 minutes) What are common causes of status epilepticus? -drug or alcohol withdrawal -sudden withdrawal from antiepileptic medication -head injury -cerebral edema -infection -fever What is Alzheimer's Disease (AD)? A chronic, progressive, degenerative disease that accounts for 60% of dementia cases in people > 60 y/o What are some clinical manifestation of AD? -manifested by loss of memory, judgment, and visuospatial perception and by a change in personality -neurofibrillary tangles are present in the brain (tangled masses of fibrous tissue throughout -neuritic plaques are composed of degenerating nerve terminals (found mostly in hippocampus [an important part of the limbic system]) in the plaques there are increased amount of abnormal proteins called beta amyloid and when they accumulate the form the neurotoxic plaques What is the cause of AD? Risk factors? It is unknown; age, gender (women more than men), and family history are the most important risk factors. What is one of the first symptoms of AD? short-term memory impairment What is the most important information to be gathered during assessment for AD? onset, duration, progression and the course of the symptoms What are the stages of AD? Stage 1: -Early (mild): first symptoms up to 4 years -independent with ADLs -no social/employment problems initially -denies presence of symptoms -forgets names; misplaces household items -short term memory loss; difficulty recalling new information -subtle changes in personality and behavior -mild cognitive impairment, problems with judgment Stage 2: -moderate (2-3 years) -impairment of all cognitive functions -problems with handling or unable to handle money and finances -disorientation to time, place, and event -possible depression, agitated -increasingly dependent with ADLs -visuospatial deficits: difficulty driving, gets lost -speech and language deficit -incontinent -wandering; trouble sleeping Stage 3: -severe -completely incapacitated; bedridden -totally dependent in ADLs -motor and verbal skills lost -general and focal neurologic deficits -agnosia (loss of facial recognition) What are labs done for dx of AD? -there are no labs that can confirm dx of AD, only a autopsy after death can confirm the presence of neurofibrillary tangles a neuritic plaques -CBC,electrolyte, EEG, CT, MRI, PET scan can be used to rule out other causes of disease What is the priority in care for AD patient? Safety: chronic confusion and physical deficits place the patient at high risk for injury What nursing interventions can be done for AD patients? -structured environment -use calendar to assist with orientation -short directions -use verbal and nonverbal communication -provide safe environment -use therapeutic touch -be consistent and repetitive -reminisce with client about the past -don't argue, "go into their world" -in early stages, reality reorientation -validation -promote self care -use short and concise sentences -routine toileting schedule -reproach if they become agitated What kind of drugs are used in patient with AD? -cholinesterase inhibitors: improve cholinergic neurotransmission in the brain by delaying the destruction of acetylcholine (slows the onset of cognitive decline) -antidepressants -psychotropic drugs Describe the concept of intracranial regulation (ICR). includes anything that affects the contents of the cranium and impacts the regulation of maintaining and optimally functioning brain What can cause disruption of intracerebral perfusion? -internal blockage of a vessel -severe hypotension -loss of vessel integrity (due to damage of excessive external pressure which exceed perfusion pressure) -intracranial hemorrhage (due to traumatic brain injury) What is normal intracranial pressure in adults? What is intracranial hypertension? -1-15 mmHg -greater than or equal to 20 mmHg What is a cerebral edema? An increase in brain size that will negatively affect perfusion and oxygenation to the brain. Causes: -brain abscess -brain tumor (primary or metastatic) -hematoma (intracerebral, subdural, epidural) -hemorrhage (intracerebral, cerebellar, brainstem) What are symptoms of increased intracranial pressure? -headache -decreased level of consciousness -vomiting What are the three components of glasgow coma scale? -eye opening -verbal response -motor response What GCS score is a coma for adults? children? -adults: less than of equal to 8 -children: less than or equal to 5 What is the earliest sign of increased intracranial pressure? -change in LOC -headache What is dehydration? fluid intake or fluid retention is less than what is needed to meet the body's fluid needs; results in fluid volume deficit, especially a plasma volume deficit