NR325 Adult Health II | Med – Surg 2 | Exam 2 (Latest
) - Chamberlain
Neurological Diagnostic Procedures - answer -Cerebral angiography
-cerebral computed tomography (CT) scan
-Electroencephalography (EEG)
-Glasgow coma Scale (GCS)
-ICP monitoring
-spinal tap
-MRI
-Positron emission tomography (PET)
-single-photon emission computed tomography (SPECT)
-radiography (x-ray)
cerebral angiography - answer *indications*: assesses bloodflow to/within brain,
identifies aneurysms, defines tumor vascularity, can be used to inject medications
*intraprocedure*
-catheter placed into artery (groin/neck), dye injected, x-rays taken
-catheter removed once pics are finished, closure device/pressure held over artery to
control bleeding by forming a thrombus and sealing the artery off.
Nursing considerations pre-cerebral angiography - answer -weigh benefits before
allowing preg patient to continue
-instruct client: NPO 4-6 hrs before and void right before
-assess for allergies
-obtain hx of bleeding/anticoags
-assess BUN/creatinine to determine ability to excrete dye
-ensure they're wearing 0 jewelry
-mild relaxing sedative sometimes administered, vitals monitored during.
-client will feel warmth through face and taste something metallic as dye is injected
Nursing considerations post-cerebral angiography - answer -closely monitor area to
ensure proper clotting
-restrict client's movements depending on procedure used to seal artery
-place ice pack on insertion site
*complications*
-risk for bleeding/hematoma @ site so
--check frequently
--if bleeding occurs, apply pressure & call HCP
-check extremity distal to puncture site for adequate circulation
Intracranial pressure - answer -normal is 10-15 mmHg, elevation minimizes cerebral
circulation and can lead to brain death
-monitoring is done for ID/treatment of > ICP.
-patients with GCS scores 8 or lower are candidates
-*s/s increased ICP:*
-severe headache
-irritability
, NR325 Adult Health II | Med – Surg 2 | Exam 2 (Latest
) - Chamberlain
-dilated pupils
-slowness
-breathing alterations
-motor fxn deterioriateion
-abnormal posturing
Lumbar puncture (spinal tap) - answer -small amount of CSF withdrawn from spinal
canal and analyzed for constituents
-used to detect presence of diseases (MS, syphilis, meningitis), reduce CSF pressure,
administer meds/chemo, instill medium/air for diagnostics
*possible complications*: brain herniation, bleeding that compresses spinal cord if PT
on anticoags.
Nursing considerations pre-lumbar tap - answer -ensure all PT jewelry gone
-instruct PT to void before
-instruct PT to get in "cannonball" position to stretch spinal canal
-local anesthetic injected into area, needle is inserted to withdraw CSF, then removed
Nursing considerations post-lumbar tap procedure - answer -monitor puncture site
(client should remain lying for several hrs to ensure site clots/decrease risk of post-
lumbar headache caused by CSF leakage)
-normal activities may be resumed after bedrest if stable
*complications*
-if clotting doesn't occur, CSF can leak, resulting in headache/infection
-prepare client for epidural blood patch to seal hole in dura if headache continues
Confusion Assessment Method - answer 1) acute onset and fluctuating course
2) inattention
3) disorganized thinking
4) altered level of consciousness
-used to assess for delirium and confusion
Seizures - answer -abrupt, abnormal electrical discharge of neurons in brain causing
alteration in LOC/motor/sensory ability and behavior
-most likely to occur 24 hrs after stroke due to increased ICP
Patient safety during seizure - answer -protect client's privacy, keep head off floor and
away from furniture
-provide patent airway, be prepared to suction oral secretions
-turn to side to decrease aspiration risk
-loosen restrictive clothing
-don't try to insert anything in mouth
-document onset/duration of seizure & findings (LOC, apnea, cyanosis, etc) before,
during, after seizure
, NR325 Adult Health II | Med – Surg 2 | Exam 2 (Latest
) - Chamberlain
Patient safety after seizure - answer -"postictal" phase
-maintain side position to prevent aspiration
-check vitals
-assess for injuries
-perform neuro checks
-allow PT to rest
-reorient/calm client
-determine if client experienced aura (can indicate seizure origin)
-try to determine possible trigger (fatigue maybe)
Seizure medication - answer -antiepileptic drugs (AED'S) like *phenytoin*
-goal is to ctrl seizure activity with ONE medication
-therapeutic lvls determined via blood tests
-educate client to take med @ same time each day
-drug decline (tolerance) over time may lead to increase in seizures
-some meds can cause gum overgrowth. dental hygiene/visits help
-when using PHENYTOIN, PT'S should avoid oral BC as it decreases their
effectiveness.
-place magnet over implantable vagal stimulator when aura sensed to prevent seizure
-warfarin should NOT be given with PHENYTOIN as it decreases absorption/increases
warfarin's metabolism
-instruct PT's to limit caffeine/looking @ flashing lights
Parkinson's Disease - answer -debilitating disease that affects motor fxn
-*main s/s*:
-tremors, muscle rigidity, bradykinesia, postural instability
-slow, shuffling gait
-slow, monotonous speech
-mask-like expression
-ortho. hypo, flushing, diaphoresis
-difficulty chewing, swallowing
-mood swings, cognitive impairment (dementia)
-*nursing diagnoses*
-Impaired Swallowing
-Impaired Verbal Communication
-Impaired Physical Mobility
-Ineffective Airway Clearance
-Risk for Aspiration
Parkinson's nursing interventions - answer -admin meds @ ordered times/monitor
effectiveness
-PRIORITY ASSESSMENT: risk for aspiration
-monitor swallowing, -maintain adequate nutrition/weight (weekly weigh)
-consult speech pathologist to determine client's risk for choking
) - Chamberlain
Neurological Diagnostic Procedures - answer -Cerebral angiography
-cerebral computed tomography (CT) scan
-Electroencephalography (EEG)
-Glasgow coma Scale (GCS)
-ICP monitoring
-spinal tap
-MRI
-Positron emission tomography (PET)
-single-photon emission computed tomography (SPECT)
-radiography (x-ray)
cerebral angiography - answer *indications*: assesses bloodflow to/within brain,
identifies aneurysms, defines tumor vascularity, can be used to inject medications
*intraprocedure*
-catheter placed into artery (groin/neck), dye injected, x-rays taken
-catheter removed once pics are finished, closure device/pressure held over artery to
control bleeding by forming a thrombus and sealing the artery off.
Nursing considerations pre-cerebral angiography - answer -weigh benefits before
allowing preg patient to continue
-instruct client: NPO 4-6 hrs before and void right before
-assess for allergies
-obtain hx of bleeding/anticoags
-assess BUN/creatinine to determine ability to excrete dye
-ensure they're wearing 0 jewelry
-mild relaxing sedative sometimes administered, vitals monitored during.
-client will feel warmth through face and taste something metallic as dye is injected
Nursing considerations post-cerebral angiography - answer -closely monitor area to
ensure proper clotting
-restrict client's movements depending on procedure used to seal artery
-place ice pack on insertion site
*complications*
-risk for bleeding/hematoma @ site so
--check frequently
--if bleeding occurs, apply pressure & call HCP
-check extremity distal to puncture site for adequate circulation
Intracranial pressure - answer -normal is 10-15 mmHg, elevation minimizes cerebral
circulation and can lead to brain death
-monitoring is done for ID/treatment of > ICP.
-patients with GCS scores 8 or lower are candidates
-*s/s increased ICP:*
-severe headache
-irritability
, NR325 Adult Health II | Med – Surg 2 | Exam 2 (Latest
) - Chamberlain
-dilated pupils
-slowness
-breathing alterations
-motor fxn deterioriateion
-abnormal posturing
Lumbar puncture (spinal tap) - answer -small amount of CSF withdrawn from spinal
canal and analyzed for constituents
-used to detect presence of diseases (MS, syphilis, meningitis), reduce CSF pressure,
administer meds/chemo, instill medium/air for diagnostics
*possible complications*: brain herniation, bleeding that compresses spinal cord if PT
on anticoags.
Nursing considerations pre-lumbar tap - answer -ensure all PT jewelry gone
-instruct PT to void before
-instruct PT to get in "cannonball" position to stretch spinal canal
-local anesthetic injected into area, needle is inserted to withdraw CSF, then removed
Nursing considerations post-lumbar tap procedure - answer -monitor puncture site
(client should remain lying for several hrs to ensure site clots/decrease risk of post-
lumbar headache caused by CSF leakage)
-normal activities may be resumed after bedrest if stable
*complications*
-if clotting doesn't occur, CSF can leak, resulting in headache/infection
-prepare client for epidural blood patch to seal hole in dura if headache continues
Confusion Assessment Method - answer 1) acute onset and fluctuating course
2) inattention
3) disorganized thinking
4) altered level of consciousness
-used to assess for delirium and confusion
Seizures - answer -abrupt, abnormal electrical discharge of neurons in brain causing
alteration in LOC/motor/sensory ability and behavior
-most likely to occur 24 hrs after stroke due to increased ICP
Patient safety during seizure - answer -protect client's privacy, keep head off floor and
away from furniture
-provide patent airway, be prepared to suction oral secretions
-turn to side to decrease aspiration risk
-loosen restrictive clothing
-don't try to insert anything in mouth
-document onset/duration of seizure & findings (LOC, apnea, cyanosis, etc) before,
during, after seizure
, NR325 Adult Health II | Med – Surg 2 | Exam 2 (Latest
) - Chamberlain
Patient safety after seizure - answer -"postictal" phase
-maintain side position to prevent aspiration
-check vitals
-assess for injuries
-perform neuro checks
-allow PT to rest
-reorient/calm client
-determine if client experienced aura (can indicate seizure origin)
-try to determine possible trigger (fatigue maybe)
Seizure medication - answer -antiepileptic drugs (AED'S) like *phenytoin*
-goal is to ctrl seizure activity with ONE medication
-therapeutic lvls determined via blood tests
-educate client to take med @ same time each day
-drug decline (tolerance) over time may lead to increase in seizures
-some meds can cause gum overgrowth. dental hygiene/visits help
-when using PHENYTOIN, PT'S should avoid oral BC as it decreases their
effectiveness.
-place magnet over implantable vagal stimulator when aura sensed to prevent seizure
-warfarin should NOT be given with PHENYTOIN as it decreases absorption/increases
warfarin's metabolism
-instruct PT's to limit caffeine/looking @ flashing lights
Parkinson's Disease - answer -debilitating disease that affects motor fxn
-*main s/s*:
-tremors, muscle rigidity, bradykinesia, postural instability
-slow, shuffling gait
-slow, monotonous speech
-mask-like expression
-ortho. hypo, flushing, diaphoresis
-difficulty chewing, swallowing
-mood swings, cognitive impairment (dementia)
-*nursing diagnoses*
-Impaired Swallowing
-Impaired Verbal Communication
-Impaired Physical Mobility
-Ineffective Airway Clearance
-Risk for Aspiration
Parkinson's nursing interventions - answer -admin meds @ ordered times/monitor
effectiveness
-PRIORITY ASSESSMENT: risk for aspiration
-monitor swallowing, -maintain adequate nutrition/weight (weekly weigh)
-consult speech pathologist to determine client's risk for choking
