NUR 2790 Final Exam Content Guide

NUR 2790 Final Exam Content Guide 1. Stroke – CVA – Brain attack disruption of cerebral blood flow secondary to ischemia, hemorrhage, brain attack, or embolism 1) Hemorrhagic – ruptured artery or aneurysm = ischemia and ↑ICP caused by expanding collection of blood. Prognosis poor. 2) Thrombotic – d/t development of blood clot on an atherosclerotic plaque in a cerebral artery. The clot gradually shuts off the artery causing ischemia distal to the occlusion. Symptoms evolve over several hours to days. 3) Embolic – d/t embolus traveling from another part of the body to the cerebral artery. Blood to brain distal to occlusion immediately shuts off causing neuro deficits, or a loss of consciousness can instantly occur. --- This type of stroke may be reversed with rtPA if given within 4.5hrs of initial symptoms. Risk Factors: HTN, DM, smoking == PREVENTION == Early treatment of HTN, maintain BGL, quit smoking. Right vs Left: Right = visual and spatial awareness and propriception. Left = language, math, and analytic thinking (agnosia – inability to recognize familiar objects). Interventions: Have suction equipment avail. Vitals 1-2hrs – Notify MD if BP 180/110. Temp (↑ can cause ↑ICP). O2 and maintain 92%. Cardiac monitor. Monitor LOC (↑ICP). Elevate HOB 30 to reduce ICP and promote venous drainage. Maintain midline neutral position. SEIZURE Percautions. Assist with communication. Assist with safe feeding. Intervene for complications r/t immobility. Active ROM to unaffected exteemities, and Passive ROM to affected extremities. Vision deficits = instruct scanning techinique (turning head). Prevent DVT. Assist with ADL’s. Provide frequent rest. Complitcations: – Prevent shoulder subluxation if affected arm is not supported. Unilateral neglect (nurse to provide arm sling/foot rest). Dysphagia and aspiration (nurse assess gag reflex, monitor swallowing). MEDS: Anticoagulant: Enoxaparin (Lovenox), warfarin (Coumadin) – Antiplatelet: Aspirin – Thrombolytic: rtPA – Antiepileptic: phenytoin (Dilantin), gabapentin (Neurontin) 2. Traumatic brain injury – major causes, eligibility for federal programs, types, assessment, interventions, rehabilitation, support, interdisciplinary care planning, sympathetic storming prevention 3. Mild brain injury – common types, assessment, interventions, patient education, prevention 4. Moderate brain injury – common types, assessment, interventions, treatments, interdisciplinary care planning, patient education, prevention 5. Increased intracranial pressure – assessment, interventions, unsafe interventions, treatments, monitoring, common medications, what to avoid, interdisciplinary care planning, patient education Treatment: Cooling blankets to lower overall body temperature. By lowering temperature of the body, the metabolic rate in the brain decreases, thus reducing metabolic demands and allowing the brain to begin to recover; Sedative or neuromuscular medications may be needed to prevent shivering and anxiety, which will increase temperature; ICP is measured by placing a small tube in the ventricles of the brain (ventriculostomy) Nursing Interventions: • Monitor the cerebral perfusion pressure, difference between the CPP is the difference between the ICP and the mean arterial pressure (MAP) • CPP is calculated by subtracting the ICP from the MAP • Keep oxygen saturation at 100% • Help with environmental stimuli; keep lights and noise low • Visitors limited to one to two for short time • Institute measures to promote healing and prevent complications; turn every 2 hours & HOB at 30 • Compression stockings • Anticoagulant therapy 6. Brain tumor- Cancer usually originates in the lung and breast but can also start in the kidney, prostate, or as lymphoma or melanoma, which then spreads to the brain - Primary brain tumor means that the cancer originated in the brain tissue; however, this type of tumor is rare - Secondary brain tumor is one that started in another location in the body and spread to the brain or CNS • Treatment: Main interventions are chemotherapy, radiation, & surgery • Potential Complications: Increased intracranial pressure 7. Hepatitis – is inflammation of the liver. Increased inflammation = necrosis interfereing with blood flow to liver. Symptoms – influenza like (Fatigue, joint pain, abd pain, ↓appetite with nausea). Dark urine. Clay stool. Jaundice. Fever. Vomiting. Labs – Elevated ALT/AST and total bilirubin NORMAL VALUES: ALT or SGPT: 10-25 units/L -- 200-400 can = hepatitis or liver damage from drugs/chemicals Jaundice caused by liver = 300 not caused by liver 300 AST or SGOT: 8-38 units/L Liver injury can ↑by 10X. Bilirubin: Total: 0.1-1.2 mg/dL adults Liver Biopsy – most definitive diagnostic approach. Need informed consent. Have Pt lie supine URQ exposed, take EXHALE breath and hold during needle insertion – resume breathing after needle withdrawn. After procedure lie in on Right side and maintain for several hours. a. Who is at risk for: i. Hepatitis A: Individuals living with infected people, sex partners of infected people, traveling to other countries - Fecal/oral route, contaminated food or water (PPE for incontinent PT’s) - Can take vaccine after exposure. ii. Hepatitis B: Health care workers or people exposed to blood and body fluids, inmates in prisons, drug users, multiple sex partners, hemodialysis patients, recipients of clotting factor concentrates - Blood, Body fluids (semen, saliva, vaginal), blood through skin and mucous membranes - Use PPE if exposure to blood. iii. Hepatitis C: IV drug users, recipients of blood products or tissue transplants before 1992, tattoos and piercings - Blood and plasma through skin and mucous membranes - Use PPE if exposure to blood. iv. Hepatitis D: coinfection with hep B b. Chronic Hepatits = B, C, or D. 8. Cirrhosis – Cirrhosis of the liver is a chronic, progressive condition characterized by destruction of the liver cells and subsequent formation of fibrotic tissue that reconfigures normal, healthy liver tissue. This lack of elasticity causes blood, bile, and lymphatic systems to become congested and obstructed, and further damage is incurred. ■ Extensive scarring of the liver caused by necrotic injury or chronic reaction to inflammation over time. ■ Signs and symptoms: Jaundice develops from liver’s inability to handle the flow of bile. Ascites. Petechiae, ecchymosis (large-yellow, purple-blue bruises), nosebleeds. Asterixis (liver flapping tremor – rapid flexion of wrists and fingers). Fetor hepaticus (liver breath – fruity or musty odor). o Causes: 3 major types of cirrhosis, which are differentiated by the underlying pathology. ▪ Laënnec’s cirrhosis - Alcoholic Cirrhosis ▪ Postnecrotic Cirrhosis: caused by viral hepatitis or certain meds or toxins. ▪ Biliary Cirrhosis: chronic biliary obstruction or autoimmune disease. ▪ Cardiac Cirrhosis: Occurs when blood flow out of the liver is restricted by severe right sided- sided failure. Tricuspid regurgitation can be associated with cardiac cirrhosis. A large amount of blood is delivered to the liver each minute. When that blood is not able to exit at a predictable rate, liver engorgement occurs and the pressure in the liver vasculature increases, causing venous congestion, anoxia or hypoxia, and hepatic cell necrosis and subsequent fibrosis. LAB: ALT/AST elevated initially due to inflammation, but then return to normal when liver is unable to produce an inflammatory response. - RBC, Hbg, hematocrit, platelet are all decreased. - Ammonia ↑ -- cirrhosis prevents conversion to urea DIAGNOSTIC: Ultrasound, Abd X-ray, CT, LIVER BIOPSY, EGD, ERCP ERCP: Endoscopic retrograde cholangiopancreatography -- used to view the biliary tract to assist in removing stones, to collect specimens for biopsy, and for placement of a stent. Interventions: Monitor Resp status – HOB 30. Skin integrity = Pruritus occurs with jaundice (use cold water and lotion to stop scratching). May need to restrict fluids (ascites, peripheral edema). Monitor neuro status for hepatic encephalopathy. DIET: high carb, fat, and protein – low sodium. If ascites – measure abd girth daily. MEDS: General meds admin’d sparingly. Give diuretics. Lactulose may be needed to rid body of ammonia thru stool. Beta Blockers if PT has varices. Procedures: Paracentesis, Surgical bypass/shunt, liver transplant, 9. Liver damage – Associated lab values, types, common treatments, assessments, interventions, support, interdisciplinary care planning, patient education 10. Liver transplant – Reasons for in children and adults, common medications associated with, lab values, monitoring, interdisciplinary care planning 11. Hemochromatosis – Assessment, diagnostic tests, lab values, interventions, treatments, interdisciplinary care planning, patient education, symptoms, support, long term effects 12. Liver disease – Common symptoms, cause of, risk factors, assessment of, interventions, diagnostic tests, lab values (abnormal), patient education, common medications, what to avoid, interdisciplinary care planning, Kernicterus, Icterus