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Terms in this set (58)

Adult Health:
-Unless contraindicated, place patient in sitting position to decrease the blood pressure
-Check patency of catheter for kinks, if occludedd, insert new catheter immediately
-check rectum for impaction
-if it is necessary to remove the impaaction, use anesthetic ointment
-administer ganglionic blocking agent such as hexamethonium or a vasodilator such as nitroprusside (Nipride)
-continue monitoring BP
-send urine for culture if no other cause is found, UTI can lead to symptoms of autonomic dysreflexia

-Raise the head of the bed
-loosen tight clothing on the client
-check for bladder distention/fecal impaction or other noxious stimulus
-administer an antihypertensive medication
-document the occurence, treatment and respsonse

Autonomic dysreflexia is characterized by severe hypertensin, bradycardia, severe headache, nasal stuffiness, and flushing. The cause is a noxious stimulus, most often a distended bladder or constipation. AD is a neurological emergency and must be treated promptly to prevent a hypertensive stroke. Immediate nursing actions are to sit the client up in bed in a high-Fowler's position and remove the noxious stimulus. The nurse would loosen any tight clothing and then check for bladder distention. If foley is in place, check for kinks in tubing and any obstruction of the flow. The nurse would also check for fecal impaction and disimpact as needed. The HCP is contacted. The nurse checks the environment to ensure that it is not too cool or drafty and monitors VS, especially BP, every 15 minutes. Antihypertensive medications may be prescribed to minimize cerebral hypertension. Finally the nurse documents the occurrence, treatment and the client's response.
-Encephalitis is an acute inflammation of the brain usually caused by a virus.
-It is a serious and sometimes fatal disease.
-Manifestations resemble those of meningitis, but with more gradual onset
Symptoms inclde:
-high fever
-changes of LOC
-cerebral edema
-mental deterioration
-personality changes
Long term symptoms include:
-memory impairment
-personality changes
-behavior abnormalities

Diagnostic tests:
-CSF studies
-PET/CT an MRI scans

Medical management:
-Mannitol (osmotic diuretis) for the cerebral edema
-Dexamethasone (corticosteroid)
-Acyclovir if caused by HSV
Medical management and nursing interventions are symptomatic and supportive.

-Inflammation of the brain parenchyma and often the meninges
-It affects the cerebrum, brainstem and the cerebellum
-Most commonly caused by a viral agent, but can be caused also by bacteria, fungi or parasites.
-Viral encephalitis is almost always preceded by a viral infection

Data collection:
-presence of cold sores, lesions or ulcerations of the oral cavity
-history of insect bites and swimming in fresh water
-exposure to infectious disease
-travel to areas where the disease is prevalent
-nausea and vomiting
-nuchal rigidity
-changes in LOS and mental status
-signs of increased ICP
-motor dysfunction and focal neurological deficit

Nursing interventions:
-monitor VS and neurological status
-Assess LOC using the Glasgow Coma Scale
-Asses for mental status and personality/behavior changes
-Asses for signs of increased ICP
-Asses for the presence of nuchal rigidity, positive Brudzinski's and Kernig;s signs indicating meningeal irritation
-Assist the client to turn, cough and deep breathe frequently

-Elevate the head of the bed to 30-45 degrees

-Asses for muscle and neurological deficits
-Administer Acyclovir (if caused by HSV), Mannitol and Dexamethasone
-Initiate rehabilitation as needed for motor dysfunction or neurological deficits.
-Meningitis is an acute infection of the meninges of the Brain.
-It is caused usually byy the following organisms:
-Neisseria meningitidis
-Heamophilus influenzae
-Meningitis can be classified as bacterial or viral

Clinical manifestations:
-Positive Kernig's and Brudzinski's signs
-Nuchal rigidity (stiff neck)
-Sudden onset with severe headache
-nausea and vomiting
-increased temperature, pulse rate and respirations
-edema of brain tissue and increased ICP

Diagnostic tests:
-CT to rule out ICP
-CSF via lumbar puncture

Medical Management:
-Antibiotic treatment
-Corticosteroids (Dexamethasone) to decrease ICP
-Anticonvulsants to prevent seizures
-Viral meningitis is treated supportively with bed rest, ensuring fluid and electrolyte balance, providing rest and comfort measures

Nursing Interventions:
-respiratory isolation until the pathogen can no longer be cultured from the nasopharynx and 24 hours after antibiotics have been initiated
-Keep room darkened and noise to a minimum
-Monitor I&O's
-IV line
-Safety precutions/seizure precautions
-manage fever (acetaminophen or cooling blankets)
-Administer Abx
-Vaccination for some forms of bacterial meningitis

-Meningitis is inflammation of the arachnoid and the pia mater of the brain and spinal cord
-Caused by bacterial or viral organisms
-Predisposing factors include:
-skull fractures
-brain or spinal surgery
-sinus or URI
-the use of nasal sprays
-compromised immune system
-CSF is analyzed (spinal tap) to determine the type and diagnosis of meningitis
-In meningitis, CSF is cloudy, with high protein, WBC's and decreased glucose count
-Transmission is by direct contact, including droplet spread

Data collection:
-Mild lethargy
-Deterioration in LOC
-Signs of meningeal irritation-Nuchal rigidity, positive Brudzinski's and Kernig's signs
-red, macular rash with meningococcal type
-abdominal and chest pain with viral meningitis

-Monitor VS and neurological status
-Assess for signs of increased ICP
-Initiate seizure and safety precautions and monitor for seizure activity
-Monitor for signs of meningeal irritation
-Perform cranial nerve assessment
-Check peripheral vascular status (Septic emboli may block circulation)
-Maintain isolation precautions with bacterial type
-Maintain stool and urine precautions with viral type
-Respiratory isolation with pneumococcal type
-Elevate head of bed to 30 degrees and avoid neck and hip flexion extreme
-Administer analgesics
-Administer antibiotics
-Rehabilitation is a goal/outcome oriented process
-The goals are personal and individualized to meet the individual's holistic needs
-To determine goals, we engage in collaborative goal-setting process that includes the members of the rehabilitation team, with the patient and the family at the center of the process
It is appropriate to include the following criteria in all rehabilitation goals:
-The goals maximize the quality of life of the individual
-The goal addresses the individual's specific needs
-The goals assist the individual with adjusting to altered lifestyle
-The goals are directed toward promoting wellness and keeping complications to a minimum
-All the goals assist the individual in attaining the highest degree of function and self-sufficiency possible
-The goals assist the individual with home and community re-entry

All rehabilitation efforts need to be outcome oriented, comprehensive and constitute an educational process

Goal of rehab is to restore the person to the highest possible level of independent functioning
Continuous and honest involvement of the family and the victim of the injury-equal participation in the rehab process is critical to successful rehabilitation for the patient with brain injury

It is critical for rehabilitation staff to be honest, professional and available in reporting rehab progress to families.

Equal communication with all family members is important, as well is encouraging the family to get involved in counseling and education

Encourage family to be aware of each other's needs and interests

Assist them to become involved in a support group/community resources
Ischemic Stroke:

-Deficient blood flow to the brain resulting from partial or complete occlusion of an artery
-Divided into Thrombotic and Embolic and accounts for about 80% of all strokes

Thrombotic Stroke:
-The most common cause of stroke
-The most common cause of cerebral thrombosis is atherosclerosis
-Hypertension, Diabetes accelerate the atheroslerotic process
-Additional risk factor include: Coagulation disorders, Polycythemia Vera, Arteritis, Chronic Hypoxia, Dehydration

-In 30-50% Thrombotic strokes have been preceded by TIA's.
-Seen most often in age group 60-90.
-Thrombois occurs in relation to injury of a blood vessel wall and formation of a blood clot. The lumen of the blood vessel becomes narrow, if occluded, leads to infarction. Thrombosis occurs where atherosclerotic plaques have already narrowed the blood vessels
-Thrombi usually occur in large blood vessels such as the carotid arteries.
-Symptoms tend to occur during sleep or soon after arising 9due to lowering BP effect and possible brain ischemia during recumbency)
-Postural Hypotension may also be a factor
-Neurologic signs and symptoms frequently worsen for the first few hours after a stroke and peak in severity within 72 hours as edema increases in the infarcted areas of the brain
-Cerebral thrombosis is a narrowing of the arteries by fatty deposits called plaque-it can cause a clot to form, which blocks the passage of blood through the artery.

Embolic Stroke:

-Second most common cause of stroke
-Occurs usually in younger people. The emboli most commonly originated from a thrombus in the endocardial layer of the heart (causes: rheumatic fever, mitral stenosis, A-fib, MI, ineffective endocarditis, valvular prosthesis, atrial septal defects)
-Less-common cause: air, fat from long bone (femur) fractures, Amniotic fluid after childbirth, Tumors
-The Embolus travels upward to the cerebral circulation and lodges where a vessels narrows or bifurcates
-It most commonly occurs in the midcerebral artery
Autonomic Dysreflexia or hyperflexia usually occurs in patients with spinal cord injuries at the sixth or higher thoracic vertebrae (T6).
The condition occurs as a result of stimulation of the bladder, large intestine or other visceral organs. Autonomic dysreflexia is an abnormal cardiovascular response to a stimulation of the sympathetic division of the autonomic nervous system.

Clinical signs include:
-severe bradycardia
-hypertension (systolic BP of 300)
-goose flesh
-flushing, above the level of the lesion
-dilated pupils
-blurred vision
-severe headache
-nasal stuffiness

The most common cause for this condition is:
-distended bladder
-fecal impaction

It is a medical emergency that requires immediate treatment to prevent stroke, blindness, or death

Emergency care for Autonomic Dysreflexia:
-Unless contraindicated, place in sitting position to decrease BP
-Check patency of foley catheter for kins, occlusion-if flow is obstructed, replace with a new one immediately
-Check rectum for impaction and dysimpact using topical anesthetic if indicated
-Administer ganglionic blocking agent such as Hexamethonium or a vasodilator (Nipride)
-Continue monitoring BP
-Send urine for culture if no other cause is found (UTI can lead to symptoms of autonomic dysreflexia)
-Perform patient teaching (self-cath, crede method, signs of infection
-Maintain adequate fluid po intake
-Perform perineal care, use of perineal pads when indicated


-Autonomic dysreflexia generally occurs after the spinal shock has resolved and with lesions at T6 or higher

Data collection:
-Sudden onset of severe, throbbing headache
-Severe Hypertension and Bradycardia
-Flushing above the level of the lesion
-Pale extremities below the level of the injury
-Nasal stuffiness
-Dilated pupils or blurred vision
-Piloerection (goose bumps)
-Restlessness, feeling of apprehension

This condition is commonly caused by visceral distention, usually the bladder or an impacted rectum. It is a neurological emergency and must be treated immediately to prevent a hypertensive stroke

Priority Nursing Actions with Autonomic Dysreflexia:
-Raise the head of the bed
-Loosen tight clothing on the client
-Check for bladder distention/fecal impaction
-Administer an antihypertensive medication
-Document the occurrence, treatment and patient's response

Also, check the environment not to be to cool or drafty and monitor VS every 15 minutes (especially BP).
Multidisciplinary approach (rehab team):
Characteristics of this model are:
-discipline specific goals
-clear boundaries between disciplines
-outcomes that are the sum of each discipline's efforts
-effective communication is the key to success

Interdisciplinary rehabilitation (The most-commonly used rehabilitation style today):
-Collaborates to identify individual's goals and features a combination of expanded problem-solving beyond the boundaries of the individual disciplines together with discipline-specific work toward goal attainment

Transdisciplinary rehabilitation team:
-the blurring of boundaries between disciplines as well as cross-training and flexibility to reduce to a minimum any duplication of effort toward individual goal attainment.

Common goal of these team rehabilitation approaches is promotion of goal-oriented care provision, good communication and collaboration between disciplines, addresses comprehensive aspects of care, energizes staff, and views the patient holistically.

The Rehabilitation Team Includes:
1. Patient-key member, participates in goals setting, takes control of own life
2. Physiatrist-Rehab physician, team leader, coordination of program
3. Rehabilitation RN-Coordinator, educator, provides support, promotes independence
4. Rehabilitation LVN-Care provider, advocate, assists in treatment plan and implementation
5. Occupational Therapist-assesses independent living needs-recommends equipment modification, adapts equipment
6. Physical therapist-Designs exercise programs, provides therapy, assesses needs, provides training
7. Speech pathologist-Designs rehabilitation communication program, assists in regaining communication skills, educator
8. Therapeutic recreation therapist-Recreation planner, activates leisure time, promotes interest in activities
9. Clinical psychologist-Emotional evaluator, assists patients in developing positive and realistic attitudes
10. Chaplain-Consultant, provides support and guidance
11. Vocational rehabilitation counselor-Vocational planner, help obtain training and employment