Summary NUR2214 Exam 3 Study Guide: Module 4

NUR2214 Exam 3 Study Guide: Module 4 Fall 2018 Part II Perfusion Definition of central perfusion • Central perfusion is generated by cardiac output—the amount of blood pumped by the heart each minute. • the presence of central perfusion is noted by heart rate and blood pressure measurements within normal limits. Impaired gas exchange • What is important for the transportation of oxygen? • What labs indicate impaired gas exchange? • Which body systems are involved? • Signs and symptoms of adequate ventilation Increased Intracranial pressure Nursing care/Nursing interventions • Monitor intake and output • Do not cluster care • Minimal stimulation • Head of bed elevated 30 degrees- head of bed elevation could decrease cerebral perfusion by increasing venous return • Suction as needed • Positioning- keep head and neck midline (to prevent compression of the jugular vein) and limit hip flexion • Activity management • Airway management • Hyperventilation- do not hyperventilate in patients with TBI because it decreased perfusion which impairs oxygen delivery • Bowel management • Nutrition management- high fiber, low sodium • Patient education • Rehabilitation Assessment • Numbness, paralysis, tingling, neuralgia • Loss of consciousness, dizziness, fainting, confusion • Changes in recent or remote memory • Changes in vision, hearing, balance, gait • Speech problems (expressive and or receptive) • Chewing/swallowing problems • Muscle weakness or loss of bowel or urinary control • Onset of unexplained tremors or other motion disturbances • Unexplained tremors or other motion disturbances • Unexplained, severe headache • Vomiting • Symptom onset and history of head injury Increased Intracranial Pressure (ICP) • Decreased level of consciousness (LOC) (lethargy to coma) • Behavior changes: restlessness, irritability, and confusion • Headache • Nausea and vomiting (may be projectile) • Change in speech pattern Aphasia Slurred speech • Change in sensorimotor status Pupillary changes: dilated and nonreactive pupils (“blown pupils”) or constricted and nonreactive pupils Cranial nerve dysfunction Ataxia • Seizures (usually within first 24 hours after stroke) • Cushing's triad Severe hypertension Widened pulse pressure Bradycardia • Abnormal posturing: Decerebrate (extensor) Decorticate (flexion) Glasgow Coma Scale  A second example of standard rapid neurologic assessment is the Glasgow Coma Scale (GCS  The GCS is used in many acute care settings to establish baseline data in each of these areas: eye opening, motor response, and verbal response.  The patient is assigned a numeric score for each of these areas. The lower the score, the lower the patient's neurologic function.  For patients who are intubated and cannot talk, record their score with a “t” after the number for verbal response.  3-15  A decrease of 2 or more points in the Glasgow Coma Scale total is clinically significant and should be communicated to the health care provider immediately. Other findings requiring urgent communication with the health care provider include a new finding of abnormal flexion or extension, particularly of the upper extremities (decerebrate or decorticate posturing); pinpoint, dilated, and nonreactive pupils; and sudden or subtle changes in mental status. Remember, changes in cognition are the earliest signs of changes in neurologic status. Early recognition of neurologic changes and communicating changes to the health care provider provide the best opportunity to prevent complications and preserve function. Intraventricular catheters  Allows accurate measurement of intracranial pressure (ICP) Allows drainage or sampling of cerebrospinal fluid (CSF) Allows instillation of contrast media Provides reliable evaluation of cerebral compliance  Disadvantages-Provides additional site for potential infection Most invasive method for monitoring ICP Must be balanced and recalibrated frequently Catheter can become occluded by blood or tissue Insertion can be difficult with small or collapsed ventricles CSF leakage can occur around insertion site Know the cranial nerves, what they do and signs and symptoms of issues with them  Assess the patient's ability to chew, which reflects the function of cranial nerve (CN) V. Assessment of the patient's ability to swallow reflects the function of CNs IX and X. In addition, note any facial paralysis or paresis (CN VII), absent gag reflex (CN IX), or impaired tongue movement (CN XII). The patient who has difficulty chewing or swallowing foods and liquids