NSG 4100 EXAM 4
Positive Kernig sign
Patient lies flat and thigh flexed on abdomen - leg unable to completely extend
Positive Brudzinski Sign
When patient neck is flexed →knees & hips flex up from straight
*More sensitive indicator than kernig
Nursing Interventions ICP
↓ Noise/Light
Cluster care
Limit visitors
Pain meds
Seizure precautions
Monitor LOC, Labs, Urine output
Drain CSF (shunt)
Priority Nursing Intervention Huntington's with pneumonia
,Respiratory support:
-Incentive Spirometer
-TCDB (turn cough deep breathe)
-Humidified O2
-CPT
Myasthenia gravis treatment
Pyridostigmine to improve muscle strength & ADL's
Myasthenia Gravis complications missed doses
Myasthenic Crisis:
Respiratory failure; neuromuscular respiratory failure may require intubation
Most common clinical manifestations Fibromyalgia
Trigger point pain
Difficulty sleeping
Nursing Education to prevent injury MS
Falls Prevention:
, Walk with feet apart to widen base
-Watch feet while walking
-Gait training
-Assistive devices (walker, cane, braces
Amyotrophic lateral sclerosis (ALS) complication
Neuromuscular weakness resulting in respiratory failure that may require intubation
Functional ability by Level of Cord Injury
-C1 - C3 possible C4
-Completely dependent for dressing, eating, elimination
-Electric wheelchair
Functional ability by Level of Cord Injury
-C4 - C5
-Maximal Assistance elimination
-Independent w/ assistance eating/dressing
Functional ability by Level of Cord Injury
Positive Kernig sign
Patient lies flat and thigh flexed on abdomen - leg unable to completely extend
Positive Brudzinski Sign
When patient neck is flexed →knees & hips flex up from straight
*More sensitive indicator than kernig
Nursing Interventions ICP
↓ Noise/Light
Cluster care
Limit visitors
Pain meds
Seizure precautions
Monitor LOC, Labs, Urine output
Drain CSF (shunt)
Priority Nursing Intervention Huntington's with pneumonia
,Respiratory support:
-Incentive Spirometer
-TCDB (turn cough deep breathe)
-Humidified O2
-CPT
Myasthenia gravis treatment
Pyridostigmine to improve muscle strength & ADL's
Myasthenia Gravis complications missed doses
Myasthenic Crisis:
Respiratory failure; neuromuscular respiratory failure may require intubation
Most common clinical manifestations Fibromyalgia
Trigger point pain
Difficulty sleeping
Nursing Education to prevent injury MS
Falls Prevention:
, Walk with feet apart to widen base
-Watch feet while walking
-Gait training
-Assistive devices (walker, cane, braces
Amyotrophic lateral sclerosis (ALS) complication
Neuromuscular weakness resulting in respiratory failure that may require intubation
Functional ability by Level of Cord Injury
-C1 - C3 possible C4
-Completely dependent for dressing, eating, elimination
-Electric wheelchair
Functional ability by Level of Cord Injury
-C4 - C5
-Maximal Assistance elimination
-Independent w/ assistance eating/dressing
Functional ability by Level of Cord Injury
