NR 325 ADULT HEALTH FINAL GUDE.| VERIFIED
GUIDE
1. How does the nurse confirm a basal skull fracture when implementing evidence based
practice? What is the nurses’ responsibility in each of these diagnosis?
Types of skull fractures: linear or depressed, simple, comminuted or compound, open or closed.
**Basilar fracture is a a specialized linear fracture involving the base of the skull (breaking of
bones at the base of the skull.) Manifestations appear over several hours which include: cranial
nerve deficits, Battle’s Sign (postauricular ecchymosis), periorbital ecchymosis (raccoon eyes).
Fracture associated with a tear in the dura and leakage of CSF. Rhinorrhea(CSF leakage for the
nose) and otorrhea(CSF leakage from the ear), this confirms the fracture has extended into the
dura. CSF leakage=high risk meningitis and antibiotics should be given as preventative. Other
Manifestations:bulging tympanic membrane caused by blood or CSF, tinnitus/hearing difficulty,
facial paralysis, conjugate deviation gaze (both eyes are deviated in the same direction) and
vertigo.
TWO Diagnostic tests used to determine if CSF is leaking from nose or ear: if there is
drainage. 1st: Dextrostix/Tes-Tape stripis used to determine if glucose is present **Remember
CSF is loaded with glucose**. (If blood present testing is unreliable because blood also contains
glucose. **Look for Halo Sign or Ring Sign**= by allowing the leaking fluid to drip onto white
gauze pad or towel and observe drainage. Within minutes, blood moves into the center and a
yellowish ring will encircle the blood if CSF is present. Note color appearance and amount of
leakage. False positive results could occur.
Major potential complications of skull fracture= intracranial infections, hematoma, meningeal and
brain tissue damaged. Also note if basilar skull fracture is suspected NG tube or oral gastric tube
should be inserted under fluoroscopy. (pg. 1369)
Intracranial Pressure Manifestations: (ATI pg. 14)Monitor for these manifestations **listed
in Question 21. **
2. What is the emergency intervention for a conscious client who has a suspected cervical
(spinal) cord injury? Identify the differences between Cervical, Thoracic, and Lumbar cord
injuries and their treatments associated with each injury. What is the nurses’ responsibility in each
of these diagnosis?
Acute care of suspected cervical (spinal) cord injury: Immobilize vertebral column, Maintence
of heart rate (atropine), and BP (dopamine), Insert NG tube and attach suction. Intubation if
needed. O2 administration by high humidity mask, indwelling catheter, administer IV fluids, stress
ulcers prophylaxsis. DVT prevention, bowel/bladder training.
1
,*C4 injury=Tetraplegia. Above C4 patient will have total loss of respiratory function (Mechanical
ventilation required) Below C4 results in diaphramgtic breathing if phrenic nerve is functioning.
2
,Nursing intervention=Patient can not cough and remove secretions, pneumonia and atelectasis can
develop.
*C6 Injury= Partial paralysis of the hands and arms and lower body
*T6 Injury=Paraplegia=Paralysis below the chest Any injury above T6, Patient will have
bradycardia & periperihal vasodilation=hypotension.
*L1 Injury= Paralegia=Paralysis below the waist. Injury above L1/L2 will convert to spastic
muscle tone after neuro shock (upper motor neuron injuries).Injury below L1/L2 convert to a
flaccid type of paralysis (Lower motor neuron injuries)\
*Autonomic dysreflexia: ATI pg. 16
Nursing Interventions: encourage active ROM exercises if possible, passive if patient lacks motor
functions. Monitor I/O, Maintain fluids to prevent urinary calculi and bladder infections. Prevent
skin breakdown, can use special bed and equipment for this. Monitor bowel sounds (ileus could
develop). Change position every 2 hours (can not feel pain or prolonged pressure). Teach about
sexual functions. Quad patients/upper motor neuron=usually capable of reflexogenic erections
(erections secondary to manual manipulation) Ejaculation coordination with emission might not
occur. Lower neuron injuries less likely to have reflexogenic erections but might be able to have
combo of reflexogenic and psychogenic erections (sexual thoughts/images).
Bowel: Use daily stool softeners or bulk-forming laxatives. Bowel movement can be stimulated
daily or everyother day by bisacodyl suppository or digital(finger) stimulation. ** Use digital
stimulation cautiously to avoid provoking a vagal response, which leads to bradycardia and
syncope.
Questions 7 lists Bladder interventions.
Patient can experience two types of shock: spinal shock: decreased reflexes, loss of sensation and
flaccid paralysis below the level of injury, can last days to month and may mask postinjury
neurological function. Neurogenic shock: contrast to spinal shock due to the loss of vasomotor
tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic
nervous system innervation causes peripheral vasodilation, venous pooling, and decreased cardiac
output. Usually associated with cervical or high thoracic injury.
**Nursing interventions for neurogenic shock: Monitor for hypotension, dependent edema, and
loss of temperature regulation (common manifestations). When Patient is upright, patient will
experience postural hypotension. When transferring a client to a wheelchair: slow and in stages
· Raise the head of the bed and be ready to lower the angle if patient gets dizzy. Transfer the
client into a reclining wheelchair with back of the wheelchair reclined. Be ready to lock and lean
the wheelchair back onto knee to a fully reclining position if the patient reports dizziness after
transfer. Do not return patient to the bed · Monitor for manifestations of thrombophlebitis (swelling
of extremity, absent/decreased pulses, and areas of warm and tenderness) Patient may need
anticoagulants to prevent development of lower extremity thrombi.
3
, 3. What are the signs of appendicitis, positive signs, the treatment, pharmacotherapy, and
what does a potential rupture, and rupture look like? What are the surgical interventions? What
is the nurses’ responsibility in each of these diagnosis?
Signs of appendicitis: Abdominal pain in the RLQ, rigid abdomen, decreased or absent bowel
sounds, fever, diarrhea/constipation, lethargy, tachycardia, rapid shallow breathing, anorexia,
possible vomiting.
Positive signs: Abdominal pain that is most intense at McBurney’s point. Rebound tenderness and
abdominal rigidity, elevated white blood cell count.
Surgical Interventions: Appendectomy
Pre-op:
**(removal of NONruptured appendix)..Laparoscopic surgery, Administer IV fluid replacement as
prescribed, Administer antibiotic.
**(removal of Ruptured)..Laparoscopic OR open surgery. Administer electrolyte and fluid
replacement as prescribed, place NG tube for decompression, administer antibiotics.
Post-op
**(NONruptured appendix)..assess respiratory status, maintain airway, provide O2 as prescribed,
vitals, administer analgesics for pain, assess surgical site or any abnormalities, assess bowel sounds
and bowel function.
**(Ruptured appendix) Same as nonruptured PLUS; Maintain NPO status, maintain NG tube to
low continuous suction. Provide wound irrigations with antibacterial solution or saline-soaked
gauze as prescribed. Provide drain care. Assess for peritonitis (fever, sudden increase in pain,
irritability, rigid abdomen, abdominal distention, tachycardia, rapid shallow breathing, pallor,
chills.
4. Identify the sign of delirium, dementia, and confusion. Which of these conditions are acute
or chronic? What is the nurses’ responsibility in each of these diagnosis?
Delirium (Acute, Temporary): state of temporary but acute mental confusion is common, life
threatening, and possibly preventable syndrome. Causes: (Also nursing actions apply to treating the
problems)
Dementia, dehydration
Electrolyte imbalances, emotional stress
Lung, liver, heart, kidney, brain
Infection, intensive care unit
Rx drugs
Injury, immobility
Untreated pain, unfamiliar environment
Metabolic disorders
Dementia (Chronic, slow progression): syndrome characterized by dysfunction or loss of
4
GUIDE
1. How does the nurse confirm a basal skull fracture when implementing evidence based
practice? What is the nurses’ responsibility in each of these diagnosis?
Types of skull fractures: linear or depressed, simple, comminuted or compound, open or closed.
**Basilar fracture is a a specialized linear fracture involving the base of the skull (breaking of
bones at the base of the skull.) Manifestations appear over several hours which include: cranial
nerve deficits, Battle’s Sign (postauricular ecchymosis), periorbital ecchymosis (raccoon eyes).
Fracture associated with a tear in the dura and leakage of CSF. Rhinorrhea(CSF leakage for the
nose) and otorrhea(CSF leakage from the ear), this confirms the fracture has extended into the
dura. CSF leakage=high risk meningitis and antibiotics should be given as preventative. Other
Manifestations:bulging tympanic membrane caused by blood or CSF, tinnitus/hearing difficulty,
facial paralysis, conjugate deviation gaze (both eyes are deviated in the same direction) and
vertigo.
TWO Diagnostic tests used to determine if CSF is leaking from nose or ear: if there is
drainage. 1st: Dextrostix/Tes-Tape stripis used to determine if glucose is present **Remember
CSF is loaded with glucose**. (If blood present testing is unreliable because blood also contains
glucose. **Look for Halo Sign or Ring Sign**= by allowing the leaking fluid to drip onto white
gauze pad or towel and observe drainage. Within minutes, blood moves into the center and a
yellowish ring will encircle the blood if CSF is present. Note color appearance and amount of
leakage. False positive results could occur.
Major potential complications of skull fracture= intracranial infections, hematoma, meningeal and
brain tissue damaged. Also note if basilar skull fracture is suspected NG tube or oral gastric tube
should be inserted under fluoroscopy. (pg. 1369)
Intracranial Pressure Manifestations: (ATI pg. 14)Monitor for these manifestations **listed
in Question 21. **
2. What is the emergency intervention for a conscious client who has a suspected cervical
(spinal) cord injury? Identify the differences between Cervical, Thoracic, and Lumbar cord
injuries and their treatments associated with each injury. What is the nurses’ responsibility in each
of these diagnosis?
Acute care of suspected cervical (spinal) cord injury: Immobilize vertebral column, Maintence
of heart rate (atropine), and BP (dopamine), Insert NG tube and attach suction. Intubation if
needed. O2 administration by high humidity mask, indwelling catheter, administer IV fluids, stress
ulcers prophylaxsis. DVT prevention, bowel/bladder training.
1
,*C4 injury=Tetraplegia. Above C4 patient will have total loss of respiratory function (Mechanical
ventilation required) Below C4 results in diaphramgtic breathing if phrenic nerve is functioning.
2
,Nursing intervention=Patient can not cough and remove secretions, pneumonia and atelectasis can
develop.
*C6 Injury= Partial paralysis of the hands and arms and lower body
*T6 Injury=Paraplegia=Paralysis below the chest Any injury above T6, Patient will have
bradycardia & periperihal vasodilation=hypotension.
*L1 Injury= Paralegia=Paralysis below the waist. Injury above L1/L2 will convert to spastic
muscle tone after neuro shock (upper motor neuron injuries).Injury below L1/L2 convert to a
flaccid type of paralysis (Lower motor neuron injuries)\
*Autonomic dysreflexia: ATI pg. 16
Nursing Interventions: encourage active ROM exercises if possible, passive if patient lacks motor
functions. Monitor I/O, Maintain fluids to prevent urinary calculi and bladder infections. Prevent
skin breakdown, can use special bed and equipment for this. Monitor bowel sounds (ileus could
develop). Change position every 2 hours (can not feel pain or prolonged pressure). Teach about
sexual functions. Quad patients/upper motor neuron=usually capable of reflexogenic erections
(erections secondary to manual manipulation) Ejaculation coordination with emission might not
occur. Lower neuron injuries less likely to have reflexogenic erections but might be able to have
combo of reflexogenic and psychogenic erections (sexual thoughts/images).
Bowel: Use daily stool softeners or bulk-forming laxatives. Bowel movement can be stimulated
daily or everyother day by bisacodyl suppository or digital(finger) stimulation. ** Use digital
stimulation cautiously to avoid provoking a vagal response, which leads to bradycardia and
syncope.
Questions 7 lists Bladder interventions.
Patient can experience two types of shock: spinal shock: decreased reflexes, loss of sensation and
flaccid paralysis below the level of injury, can last days to month and may mask postinjury
neurological function. Neurogenic shock: contrast to spinal shock due to the loss of vasomotor
tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic
nervous system innervation causes peripheral vasodilation, venous pooling, and decreased cardiac
output. Usually associated with cervical or high thoracic injury.
**Nursing interventions for neurogenic shock: Monitor for hypotension, dependent edema, and
loss of temperature regulation (common manifestations). When Patient is upright, patient will
experience postural hypotension. When transferring a client to a wheelchair: slow and in stages
· Raise the head of the bed and be ready to lower the angle if patient gets dizzy. Transfer the
client into a reclining wheelchair with back of the wheelchair reclined. Be ready to lock and lean
the wheelchair back onto knee to a fully reclining position if the patient reports dizziness after
transfer. Do not return patient to the bed · Monitor for manifestations of thrombophlebitis (swelling
of extremity, absent/decreased pulses, and areas of warm and tenderness) Patient may need
anticoagulants to prevent development of lower extremity thrombi.
3
, 3. What are the signs of appendicitis, positive signs, the treatment, pharmacotherapy, and
what does a potential rupture, and rupture look like? What are the surgical interventions? What
is the nurses’ responsibility in each of these diagnosis?
Signs of appendicitis: Abdominal pain in the RLQ, rigid abdomen, decreased or absent bowel
sounds, fever, diarrhea/constipation, lethargy, tachycardia, rapid shallow breathing, anorexia,
possible vomiting.
Positive signs: Abdominal pain that is most intense at McBurney’s point. Rebound tenderness and
abdominal rigidity, elevated white blood cell count.
Surgical Interventions: Appendectomy
Pre-op:
**(removal of NONruptured appendix)..Laparoscopic surgery, Administer IV fluid replacement as
prescribed, Administer antibiotic.
**(removal of Ruptured)..Laparoscopic OR open surgery. Administer electrolyte and fluid
replacement as prescribed, place NG tube for decompression, administer antibiotics.
Post-op
**(NONruptured appendix)..assess respiratory status, maintain airway, provide O2 as prescribed,
vitals, administer analgesics for pain, assess surgical site or any abnormalities, assess bowel sounds
and bowel function.
**(Ruptured appendix) Same as nonruptured PLUS; Maintain NPO status, maintain NG tube to
low continuous suction. Provide wound irrigations with antibacterial solution or saline-soaked
gauze as prescribed. Provide drain care. Assess for peritonitis (fever, sudden increase in pain,
irritability, rigid abdomen, abdominal distention, tachycardia, rapid shallow breathing, pallor,
chills.
4. Identify the sign of delirium, dementia, and confusion. Which of these conditions are acute
or chronic? What is the nurses’ responsibility in each of these diagnosis?
Delirium (Acute, Temporary): state of temporary but acute mental confusion is common, life
threatening, and possibly preventable syndrome. Causes: (Also nursing actions apply to treating the
problems)
Dementia, dehydration
Electrolyte imbalances, emotional stress
Lung, liver, heart, kidney, brain
Infection, intensive care unit
Rx drugs
Injury, immobility
Untreated pain, unfamiliar environment
Metabolic disorders
Dementia (Chronic, slow progression): syndrome characterized by dysfunction or loss of
4
