Term
| If a client arrives in the ER with a head injury. What changes in the clients VS would you expect if they are having signs of increased ICP? |
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Definition
| Rise in BP with a pulse pressure that is widening and slowing. Initial VS may be: 120/80 & 88. Later: 130/80 & 68. Later 145/90 & 60. |
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Term
| What is a contre coup injury? |
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Definition
| bruising of the brain opposite the site of impact. It will hit the frontal lobe & the brain will also bruise the back, the temporal lobe. |
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Term
| After a head injury, there is discharge from the nose or ear. What test should be done? |
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Definition
| The Halo Test. Use white gauze & dab the site. After a few minutes, if there is blood in the center, surrounded by a yellow circle, there is leakage of the CSF, positive halo sign. |
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Term
| If there is a head injury & the person loses consciousness, but then regains it and is talking about how they are fine. They're having a 'lucid interval'... what would you suspect? |
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Definition
| Epidural Hematoma. Bleeding in an artery. This is bleeding between the dura and the inner surface of the skull. It has a faster onset & is characterized by the "lucid interval." |
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Term
| If a pt's pupils are changed from one assessment from the next, what should the nurse do? |
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Definition
| Notify the physician asap, signs of ICP |
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Term
| What is important to remember when suctioning a patient with a head injury? |
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Definition
| You only suction when it is necessary. Because coughing, raising the head off the bed will all increase their ICP more. |
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Term
| If your head injury patient is awake and responding now, but reports he has no sense of smell. What cranial nerve has damage to it? |
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Definition
| Cranial Nerve I, Olfactory |
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Term
| A pt has an open head injury with lacerations. What major complications are they at risk for? |
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Definition
| Infection. Especially, bacterial meningitis. |
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Term
| The nurse gives you report and says the pt is showing signs of DECORTICATE posturing. What does this look like? |
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Definition
| The response is to the core. They bring their arms up to their chest. "client flexes one or both arms on the chest and may extend the legs stiffly." |
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Term
| If a pt has injuries to L1-5, where are the deficits? |
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Definition
| In the hip girdle, hips, thighs, hamstrings. So, lower extremities. |
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Term
| Your pt comes to the ER after a car wreck. What are some signs of possible spinal injury, just by looking at him? |
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Definition
| Contusion or laceration on his forehead. Or a starburst on his car windshield. |
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Term
| You're taking care of a quad that is 2 months post injury. He's c/o a severe headache, is flushed, has blurred vision & is diaphoretic. His BP is 210/120. What is likely happening? |
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Definition
| Autonomic Dysreflexia. Assess for interventions: check to see if Foley is blocked, if he's constipated or if the room is too cold. Give meds to lower his BP. (Hydralazine or Apresoline) |
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Term
| What are the priority nursing concerns with C6-7 injuries? |
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Definition
| Airway, breathing & Circulation. If you know it's C6-7, there may be some swelling of the cord, which may effect the diaphragmatic innervation. |
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Term
| What would you notice if the patient was in spinal shock? |
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Definition
| Hypotension, bradycardia & hypothermia. Also, if flaccid paralyis, then the absence of deep tendon reflexes below level of lesion. (Spinal shock occurs immediately or w/in an hour of injury and is the loss of communication pathways between the upper and lower motor neurons) The muscles become completely paralyzed and flaccid, and reflexes are absent. |
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Term
| If your client has expressive aphasia (can't comprehend language). How do these patient's typically relearn? |
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Definition
| They learn the alphabet first. Teach them how to spell out the sounds. |
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Term
| Pt being admitted to the ER who c/o earlier episodes of right sided weakness, confusion and trouble speaking that lasted about an hour. What do you expect? |
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Definition
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Term
| For a pt who recently had a TIA, where are you going to focus their assessment? |
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Definition
| Neuro. So, do the Glasgow Coma Scale, I think. |
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Term
| The physician wants to determine whether the stroke is ischemic or hemorrhagic. What will be done? |
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Definition
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Term
| To order TPA, the CT scan showed what? |
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Definition
| The CT scan should be negative for hemorrhagic. Can only use TPA with ischemic strokes. If it shows a bleed, that means NO TPA. It can show areas of subacute or chronic infarct though. |
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Term
| What intervention is employed to reduce the risk of aspiration pneumonia in pt's who had a stroke? |
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Definition
| elevate the HOB to 30 degrees. |
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Term
| For a CVA (stroke), what drug might the physician order to reduce the brain swelling? |
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Definition
| Mannitol, an osmotic diuretic |
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Term
| When the client comes in with left hemiplegia, what part of the brain is damaged? |
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Definition
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Term
| Your client with a CVA has visual field deficits. What interventions do you know you need to assist with? |
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Definition
| Place items where they can see them. |
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Term
| What medications are given for autonomic dysreflexia? |
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Definition
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Term
| What is the rationale for giving Solu-Medrol to a SCI patient? |
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Definition
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Term
| A client is admitted w/ burns on their head, neck, back and arms. Upon admission, you ausculate their lungs and hear wheezes. A bit later, they've developed a respiratory stridor. What are you going to do? |
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Definition
| Notify the physician, they need to be intubated. |
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Term
| A pt suffers burn injuries in an enclosed space. They have singed nose hairs and soot under their nose. What do you suspect? |
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Definition
| Inhalation injury. Likely will need intubation. |
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Term
| What is the best route to give pain meds for a burn patient? |
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Definition
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Term
| If your patient has cellulitis, what nursing intervention is necessary? |
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Definition
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Term
| How do we prevent skin cancer in pt's who are at risk? |
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Definition
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Term
| What is the priority nursing diagnosis for a patient with Psoriasis? |
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Definition
| Altered Body Image (Psoriasis is a chronic, non-contagious autoimmune disease characterized by red scaly patches) |
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Term
| To enhance skin absorption when you've applied a topical steroid, what would you do? |
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Definition
| Apply a warm, moist dressing and occlusive wrap. |
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Term
| Your pt has Uticaria (HIVES!). The pt is going to take Benadryl, an antihistamine. What should you recommend? |
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Definition
| Take the med at bedtime b/c Benadryl makes you sleepy and when they go to bed, the itching really starts. |
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Term
| Your patient has extensive burn injuries, what is used to prevent contractures? |
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Definition
| pressure garmets and splinting prevent muscle shortening |
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Term
| When they position the extremities, what is the ideal position? Do they use flexion or extension? |
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Definition
| Extension. (they would get tight + scar in flexed position) |
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Term
| Nutritional therapy is done for a burn patient. What is the ideal route? Tube feeding or parenteral? |
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Definition
| Tube feeding if their GI is moving along b/c parenteral has a high risk for infection. The tube feeding additionally generates enzyme activity in the gut that prevents sepsis. |
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Term
| After the initial phase of injury and fluids are under control, the plan of care becomes focused on... |
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Definition
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