BNKN602 EXAM QUESTIONS AND ANSWERS WITH COMPLETE
SOLUTIONS GRADED A++
Autonomic dysreflexia patho
Autonomic dysreflexia occurs in people with spinal cord injury at or above T6.
1) A noxious stimulant below the level of injury occurs, this stimulant could be a
distended bladder or bowel, an ingrown toenail, kinked catheter.
2) This results in a extreme sympathetic response causing widespread vasoconstriction
3) The vasoconstriction of the blood vessels cause a rapidly increasing blood pressure
4) The brain is signaled by baroreceptors about the bodies hypertensive crisis and in an
attempt to lower the blood pressure, the heart rate is decreased and the person can
become bradycardic
5) inhibitory signals are unable to pass below the injury from being transmitted further
down the spinal cord.
If noxious stimulant is not removed, it can result in significant complications such as
stroke, seizures, myocardial ischemia or death.
Common causes of autonomic dysreflexia
Urinary retention
Over distended bladder or bowel
Pressure ulcers
Kidney stones
Ingrown toenail
,Interventions for autonomic dysreflexia
• Put the person into sitting position 90◦ to help lower the BP
• Assess for the probable cause and remove
• Continue to assess vital signs (Q2-3min BP)
• Administer GTN as prescribed if SBP > 150mmHg (short acting anti-hypertensive
medications only) • Loosen clothing
Cushing's triad
Signs of increased intracranial pressure:
1. hypertension
2. bradycardia
3. irregular respirations
Symptoms of a stroke
Face--Sudden weakness and/or numbness of face,
Arms--Sudden weakness of the arm (and/or leg)
Speech--Difficulty speaking, words jumbled, or lost voice
Interventions for a stroke
• To monitor for further neurological deterioration and maintain patient safety
• Maintain head of bed 30◦
• Maintain systolic blood pressure within prescribed parameters (often < 180mmHg)
• Continuous neurological observations
• Ensure correct positioning of paralysed limbs
• Ensure patient is kept NBM until swallow is assessed by Speech and Language
Therapist
,• Administer prescribed aspirin orally or enterally
• Turn the patient regularly
Prolonged hypertension results in
Permanent damage to the arterial walls
Ischaemic heart disease
A chronic disease caused by insufficient blood supply (thus O2) to the heart muscles via
the coronary arteries typically resulting from Atherosclerosis.
Ischaemic heart disease- Interventions
-Monitor BP
-Encourage low fat, high protein diet
Angina
chest pain due to obstruction of a major coronary artery resulting in decreased oxygen
supply
Myocardial infarction- signs and symptoms
-Chest pain - may radiate down arm
-shortness of breath
-diaphoresis (sweating)
-Palpitations
-Increased Jugular venous distention if MI has caused HF
-Weak thready pulse
-Pale, cyanosis
-Hypoxaemia
, -Nausea
-SOB, dyspnoea
Ischaemic heart disease- Signs and symptoms
-angina
-dizziness
-nausea
-SOB
-^HR
Myocardial infarction (MI)
Heart attack; death of myocardial tissue (infarction) caused by ischemia (loss of blood
flow) as a result of an occlusion (plugging) of a coronary artery; usually caused by
atherosclerosis
Myocardial infarction interventions
-Interventions for MI
-Monitor vital signs record and report
-Administer prescribed 02
-Administer prescribed GTN to promote vasodilation and therefore increase 02 delivery
-Administer prescribed aspirin to inhibit platelet formation of thrombus
-Administer prescribed opioids or analgesia to decrease chest pain and regularly
elevate pt response
-Reassure pt and family to reduce level of anxiety, therefore decrease WOB and
decrease RR
SOLUTIONS GRADED A++
Autonomic dysreflexia patho
Autonomic dysreflexia occurs in people with spinal cord injury at or above T6.
1) A noxious stimulant below the level of injury occurs, this stimulant could be a
distended bladder or bowel, an ingrown toenail, kinked catheter.
2) This results in a extreme sympathetic response causing widespread vasoconstriction
3) The vasoconstriction of the blood vessels cause a rapidly increasing blood pressure
4) The brain is signaled by baroreceptors about the bodies hypertensive crisis and in an
attempt to lower the blood pressure, the heart rate is decreased and the person can
become bradycardic
5) inhibitory signals are unable to pass below the injury from being transmitted further
down the spinal cord.
If noxious stimulant is not removed, it can result in significant complications such as
stroke, seizures, myocardial ischemia or death.
Common causes of autonomic dysreflexia
Urinary retention
Over distended bladder or bowel
Pressure ulcers
Kidney stones
Ingrown toenail
,Interventions for autonomic dysreflexia
• Put the person into sitting position 90◦ to help lower the BP
• Assess for the probable cause and remove
• Continue to assess vital signs (Q2-3min BP)
• Administer GTN as prescribed if SBP > 150mmHg (short acting anti-hypertensive
medications only) • Loosen clothing
Cushing's triad
Signs of increased intracranial pressure:
1. hypertension
2. bradycardia
3. irregular respirations
Symptoms of a stroke
Face--Sudden weakness and/or numbness of face,
Arms--Sudden weakness of the arm (and/or leg)
Speech--Difficulty speaking, words jumbled, or lost voice
Interventions for a stroke
• To monitor for further neurological deterioration and maintain patient safety
• Maintain head of bed 30◦
• Maintain systolic blood pressure within prescribed parameters (often < 180mmHg)
• Continuous neurological observations
• Ensure correct positioning of paralysed limbs
• Ensure patient is kept NBM until swallow is assessed by Speech and Language
Therapist
,• Administer prescribed aspirin orally or enterally
• Turn the patient regularly
Prolonged hypertension results in
Permanent damage to the arterial walls
Ischaemic heart disease
A chronic disease caused by insufficient blood supply (thus O2) to the heart muscles via
the coronary arteries typically resulting from Atherosclerosis.
Ischaemic heart disease- Interventions
-Monitor BP
-Encourage low fat, high protein diet
Angina
chest pain due to obstruction of a major coronary artery resulting in decreased oxygen
supply
Myocardial infarction- signs and symptoms
-Chest pain - may radiate down arm
-shortness of breath
-diaphoresis (sweating)
-Palpitations
-Increased Jugular venous distention if MI has caused HF
-Weak thready pulse
-Pale, cyanosis
-Hypoxaemia
, -Nausea
-SOB, dyspnoea
Ischaemic heart disease- Signs and symptoms
-angina
-dizziness
-nausea
-SOB
-^HR
Myocardial infarction (MI)
Heart attack; death of myocardial tissue (infarction) caused by ischemia (loss of blood
flow) as a result of an occlusion (plugging) of a coronary artery; usually caused by
atherosclerosis
Myocardial infarction interventions
-Interventions for MI
-Monitor vital signs record and report
-Administer prescribed 02
-Administer prescribed GTN to promote vasodilation and therefore increase 02 delivery
-Administer prescribed aspirin to inhibit platelet formation of thrombus
-Administer prescribed opioids or analgesia to decrease chest pain and regularly
elevate pt response
-Reassure pt and family to reduce level of anxiety, therefore decrease WOB and
decrease RR
