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Terms in this set (73)

score
15: highest possible score
motor response points
6: obeys a simple response
5: localizes painful stimuli
4: normal flexion (withdrawal)
3: abnormal flexion (decorticate)
2: extensor response (decerebrate)
1: no motor response to pain
verbal response points
5: oriented
4: confused conversation
3: inappropriate words
2: responds with incomprehensible sounds
1: no verbal response
eye-opening points
4: spontaneous
3: in response to sound
2: in response to pain
1: no response even to painful stimuli
NCLEX 801
eyes open
approach to bedside
verbal command
pain
4: spontaneous response
3: opening of eyes to name or common
2: lack of opening of eyes to previous stimuli but opening to pain
1: lack of opening of eyes to any stimulus
U: untestable
best verbal response
verbal questioning with maximum arousal
5: appropriate orientation, conversant; correct identification of self, place, year, and mouth
4: confusion; conversant, but disorientation in one or more spheres
3: inappropriate or disorganized use of words (e.g., cursing), lack of sustained conversation
2: incomprehensible words, sounds (e.g., moaning)
1: lack of sound, even with painful stimuli
U: untestable
best motor response
verbal command (e.g., "raise your arm, hold up two finger")
pain (pressure on proximal nailbed)
6: obedience of command
5: localization of pain, lack of obedience but presence of attempts to remove offending stimulus
4: flexion withdrawal, flexion of arm in response to pain without abnormal flexion posture
3: abnormal flexion, flexing of arm at elbow and pronation, making a fist
2: abnormal extension, extension of arm at elbow usually adduction and internal rotation of arm at shoulder
1: lack or response
U: untestable
AHN 659
-monitor VS and neurological status every 30 minutes to 1 hour
-monitor for increased ICP
-monitor for decreased LOC, motor weakness or paralysis, aphasia, visual changes and personality changes
-maintain mechanical ventilation and slight hyperventilation for the first 24 to 48 hours as prescribed to prevent increased ICP
-check the HCP's prescriptions regarding client posturing
-avoid extreme hip or neck flexion, and maintain the head in a midline neutral position
-provide a quiet environment
-monitor the head dressing frequently for signs of drainage
-mark any area of drainage at least once each nursing shift for baseline comparison
-monitor the hemovac of jackson-pratt drain, which may be in place for 24 hours
-monitor suction on the hemovac of jackson-pratt drain
-measure drainage from the hemovac of jackson-pratt drain every 8 hours, and record the amount and color
-notify the HCP if drainage is greater than the normal of 30 to 50 mL per shift
-notify the HCP immediately of excessive amounts of drainage or a saturated head dressing
-provide basic hygiene
-record strict measurement of hourly intake and output
-maintain fluid restriction at 1500 mL/day as prescribed
-monitor electrolyte values
-monitor for dysrhythmias, which may occur as a result of fluid and electrolyte imbalance
-apply ice packs or cool compresses as prescribed; expect periorbital edema and ecchymosis of one or both eyes which is not an unusual occurrence
-turn and position every 2 hours and provide ROM exercises every 8 hours
-prevent development of DVT and place anti embolism stockings on the client as prescribed
-administer analgesics such as codeine sulfate and acetaminophen (Tylenol) as prescribed for pain
NCLEX 805
the patient may have residual motor or sensory problems as a result of the tumor or surgery
AHN 708
1. provide bed rest during exacerbation
2. protect the client from injury by providing safety measures
3. place an eye patch on the eye for diplopia
4. monitor for potential complications such as UTI, calculi, pressure ulcers, respiratory tract infections, and contractures
5. promote regular elimination by bladder and bowel training
6. encourage independence
7. assist the client to establish a regular exercise and rest program
8. instruct the client to balance moderate activity with rest periods
9. assess the need for and provide assistive devices
10. initiate physical and speech therapy
11. instruct the client to avoid fatigue, strew, infection, overheating, and chilling
12. instruct the client to increase fluid intake and eat a balanced diet, including low-fat, high-fiber foods and foods high in potassium
13. instruct the client on safety measures related to sensory loss, such as regulating the temperature of bath water and avoiding heating pads
14. instruct the client on safety measure related to motor loss, such as avoiding the use of scatter rugs and using assistive devices
15. instruct the client in the self-administration of prescribed medications
16. provide information about the national MS society
NCLEX 814
nutrition
-well-balanced diet with high-fiber foods and adequate fluids is important
-no standard prescribed diet, a high-protein diet with supplemental vitamins is often recommended
skin care
-frequent turning to avoid skin impairment
-devices to relieve pressure (eggcrate or air mattresses)
-because of sensory involvement, the patient may not feel discomfort that signals the need to change position
activity
-exercise regularly, but not to the point of fatigue
-physical therapy sometimes improves neurologic dysfunction
-decreases spasticity, increases coordination, retrains unaffected muscles to substitute for impaired ones
control of environment
-avoid hot baths, increase weakness
-summer travel during coolest part of day, where air-conditioned
-do best in peaceful and relaxed environments
AHN 682
antiseizure drugs
phenytoin sodium (Dilantin)
divalproex (Depakote)
oxcarbazepine (Trileptal)
phenobarbital (Luminal)
primidoen (Mysoline)
Ethosuximide (Zarontin)
trimethadione (Tridiond)
diazepam (Valium)
carbamazepine (Tegretol)
valproic acid (Depakene)
clonazepam (Klonopin)
mephenytoin (Mesantoin)
gabapentin (Neurontin)
lamotrigine (Lamictal)
felbamate (Felbatol)
fosphenytoin sodium (Cerebyx)
topiramate (Topamax)
tiagabine (Gabitril
levetiracetam (Keppra)
zonisamide (Zonegran)
AHN 679
anticonvulsant medication
hydantoins
-treat partial and generalized tonic-clonic seizures
-phenytoin also is used to treat dysrhythmias
ethotoin (Peganone)
fosphenytoin (Cerebyx)
phenytoin (Dilantin)
barbiturates
-tonic-clonic seizures and acute episodes caused by status epileptics
-also used as adjuncts to anesthesia
amobarbital (Amytal)
mephobarbital (Mebaral)
phenobarbital (Luminal)
benzodiazepines
-treat absence seizures
-diazepam and lorazepam treat status epileptics, anxiety and skeletal muscle spasms
-clorazepate used as adjunctive therapy for partial seizures
clonazepam (Klonopin)
clorazepate (Tranxene)
diazepam (Valium)
lorazepam (Ativan)
Zolpiden (Ambien)
succinimides
-treat absence seizures
ethosuximide (Zarontin)
methsuximide (Celontin)
oxazolidinedione
-absence seizures
trimethadione (Troxidone)
valproates
-tonic-clonic, partial, myoclonic, and psychomotor seizures
valproic acid (Depakene, Depacon)
devalproex sodium (depakote ER)
iminostilbenes
-treat seizure disorders that have not responded to other antivonculsants
-trigeminal neuralgia
carbamazepine (Tegretol
gabapentin (Neurontin)
lamotrigine (Lamictal)
levetiracetam (Keppra)
oxcarbazepine (Trileptal)
pregabalin (Lyrica)
tiagabine (Gabitril Filmtab)
topiramate (Topamax)
zonisamide (Zonegran)
vigabatrin (Sabril)
NCLEX 827
if the client is having a seizure, maintain a patent airway; do not force the jaws open or place anything in the client's mouth
1. note the time and duration of the seizure
2. assess behavior at the onset of the seizure; note if the client experienced an aura, a change in facial expression occurred, or a sound or cry occurred form the client
3. if the client is standing, place him or her on the floor and protect the head and body
4. support the ABCs-airway breathing, and circulation
5. administer oxygen
6. prepare to suction secretions from the airway
7. turn the client to the side, to allow secretions to drain, while maintaining the airway
8. prevent injury during the seizure
9. remain with the client
10. do not restrain the client
11. loosen restrictive clothing
12. note the type, character, and progression of the movements during the seizure
13. monitor for incontinence
14. administer IV medications as prescribed to stop the seizure
15. document the characteristics of the seizure
16. provide privacy, if possible
17. monitor behavior after the seizure, such as the state of consciousness, motor ability, and speech ability
NCLEX 811
-protection from aspiration and injury
-observation and recording of the seizure activity; what preceded, when occurred, length of each phase; what occurred in each phase
-never leave patient alone
-if sitting or standing, lower him or her to the floor in an area away from furniture and equipment
-support and protect the head; if possible turn the head to the side to maintain airway
-if there is time, loosen clothing around the neck
-do not try to restrain
-do not pry open the jaw to place a padded tongue blade
-no objects should be placed in the mouth
AHN 679