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Neuro Exam #2-Med Surg

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Pt. has comminuted fracture at the Level of T6-7, paraplegia, symptoms of autonomic dysreflexia, what triggers that? Key-know T6-7 what are they responsible for?
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T6-T12 Vagus nerve domination only of leg vessels, GI and genitourinary organs
Movement remaining: Full, stable thoracic muscles and upper back, functional intercostals, resulting in increased respiratory reserve
Rehab potential:Full independent use of wheelchair, ability to stand erect with full leg brace, ambulate on crutches with swing (although gait difficult), inability to climb stairs.

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.
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
-do not rush or pressure the patient to communicate, allow for time to process information and express self
-use of alternative methods of communication-board, sign language

Nursing Diagnoses:
*Impaired verbal communication related to ischemic injury:
-speak slowly and distinctly
-ask questions that can be answered by yes or no (or by signals)
-try to anticipate patient needs
-call bell within reach at the unaffected side
-begin speech therapy asap

Interventions for Aphasia:
-provide repetitive directions
-break tasks down to one step at a time
-repeat names of objects frequently used
-allow time for the client to communicate
-use of picture, communication board, or computerized technology
-encourage to express feelings
-refer to speech and language pathologists
*Imbalanced nutrition, less than body requirements, r/t impaired ability to swallow:
-Provide IV fluids and tube feedings as prescribed during the initial period
-refer to speech therapy for assessment of swallowing problems
-asses ability to swallow before initiating feedings
-position patient with head elevated and head turned to the unaffected side while feeding
-provide foods easy to swallow-except mashed potatoes
-avoid thin liquids and thicken them before giving
-do not give milk roduces, increase viscosity of mucus secretions and increase salivation
-use a training cup for fluids as necessary
-do not use a straw
-expect mouth for trapped food in cheek pockets
-be patient hen feeding the patient and provide directions for swallowing as needed. Provide unrushed and nonstressful meal times
-encourage self-feeding asap, provide self-help devices, adaptive utensils, plate guards
-provide meticulous oral hygiene
-West-Nile virus is contracted via bite of an infected mosquito
-Use insect repellents containing DEET and that provides protection for the amount of time spent outdoors and when outdoors and wear long sleeves and pants and light-colored clothing
-Also spray clothing because mosquitoes can bite through thin clothing
-Stay indoors at dusk and dawn when mosquitoes are most active
-Ensure that mosquito breeding sites are eliminated, such as standing water and water in bird baths, and keep wading pools empty and on their sides when not in use
-Take special precautions in the months from April through October when mosquitoes are most active
-DEET is the gold standard in currently available OTC insect repellents
-Place mosquito nets over baby strollers and carriers
-Keep pools, saunas and hot tubs clean and properly chlorinated
-Do not store any containers that may become filled with standing water outdoors
-Install/repair window and door screens so that mosquitoes cannot get indoors
Autonomic dysreflexia or hyperflexia generally occurs after the period of spinal shock is resolved and occurs with lesions or injuries above the T6 level and in cervical lesions.
It is commonly caused by visceral distention from a distended bladder or impacted rectum.

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 flesh/bumps)
Adult Health:
-Unless contraindicated, place patient in sitting position to decrease the blood pressure
-Check patency of catheter for kinks, if occluded, insert new catheter immediately
-check rectum for impaction
-if it is necessary to remove the impaction, 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 hypertension, 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.
-Nuchal rigidity (stiff neck)
-Positive Kernig's sign (the inability to extend the legs completely without extreme pain)
-Positive Brudzinski's sign (flexion of the hip and knee when the neck is flexed)
-sudden onset with severe headache
-nausea and vomiting
-increased temperature, respirations and pulse rate

Data collection:
-deterioration of LOC
-signs of meningeal irritation such as nuchal rigidity, positive Brudzinski's and Kernigs signs
-red, macualr rash wth meningococcal meningitis
-abdominal and chest pain with viral meningitis
-CSF is cloudy, with increased protein, increased WBC's count, and decreased glucose counts
Specific gravity: 1.007
Chloride-120-130 mEq/L
Glucose-50-75 mg/dL
Pressure-80-200 mm H2O
Total volume-80-200 ml (15 ml in ventricles)
Total Protein- 15-45-lumbar
Gamma globulin-6-13% of total protein
Cell count:
C&S-No organisms present
Serology for syphilis-Negative
Comfort measures for patients with trigeminal neuralgia:
-keep room free of drafts, moderate temperature
-avoid walking briskly to bedside of patient
-place bed out of traffic area to prevent jarring of the bed
-avoid touching the patient's face
-do not urge patients to wash or shave the affected area or to comb their hair during acute attack
-stress importance of hygiene, nutrition and oral care
-provide soft cloths and cotton saturated with solution for cleansing that face that do not require water
-warm mouthwash and soft, small toothbrush
-instruct on matters of hygiene,when analgesia is at it's peak
-avoid hot or cold liquids which trigger pain
-pureed food that is lukewarm. Food may need to be taken through a straw

Permanent relief of pain is obtained only through surgery that involves inserting of fine needle through the cheek and injecting an alcohol solution or resecting the sensory root of the trigeminal nerve.

-instruct the client to avoid hot or cold foods and fluids
-provide small feeding of liquid and soft foods that are lukewarm
-instruct client to chew food on the unaffected side
-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 by the following organisms:
-Neisseria meningitis
-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