A+E 2 FINAL NYU
Terms in this set (108)
Tests LOC of patient.
Glasgow Coma Scores
Scale: what is it?
scores? highest: 15 (fully
when to call HCP? conscious) lowest: 3
(borderline dead)
Danger: less than 8
intubate
call HCP if there is ANY change AT ALL in the pt GCS !
Bell's Palsy is when one side of the face becomes paralyzed.
Symptoms eventually resolve on their own.
, We want to rule out stroke
Bell's Palsy: what is it? what do
we want to rule out? nursing
priorities ? Nursing Care
- aspiration risk (tell the patient to chew on the unaffected side)
- corneal abrasions bc eyes can't close. Tell the patient to
use eye drops or an eye patch.
Bell's Palsy
- face drooping ONLY
- symptoms resolve on their own usually
Bell's Palsy vs. Stroke: what are
the differences?
Stroke
- OTHER SYMPTOMS IN ADDITION TO FACIAL DROOPING:
slurring speech, vision change, weakness.
- damage can be PERMANENT
, Trigeminal neuralgia (anything algia means pain) is a brief
acute facial pain/ twitching. The pain can be described as
sharp or "knife-like"
Triggers: chewing, brushing teeth, hot/cold, touch. Because of
Trigeminal Neuralgia: what is
this, patient may avoid hygiene and eating!
it? describe the pain? what are
the triggers and what can
this lead to? Nursing care? Nursing:
- limit triggers during acute phases.
- adequate hydration + nutrition
G.B.S is a rare destruction/inflammation of the nerves
accompanied by ascending muscle weakness + paralysis.
The autonomic nervous system is
impacted. Priorities:
- Airway + breathing (due to ascending paralysis/resp deprerssion)
- BP (can cause orthostatic hypotension) + HR
Guillan Barre Syndrome: what
is it? Which system is affected? - prevent immobility
What are the priorities?
Chronic autoimmune disease of disruption in neuronal
signals (myelinated). Triggers: fatigue, overexertion,
stress, hot temp ( avoid hot showers )
Diagnosis:
Multiple Sclerosis: what is it?
Triggers? diagnosis? - takes a long time
- no one knows why. Vit D deficiency is suspected
(higher incidences in people farther from equator/sun)
- IgG and lesions on MRI can help diagnose
M.S. affects patient's mood causing depression, anger, and
euphoria. Tell pt that these are normal side effects and that
we will help them through it. M.S. also affects GI/GU +
sexual dysfunction.
Nursing Considerations for
Multiple Sclerosis : what does
, it affect and what should we tell Our priority is ADLs for our patient!
the patient? Priority?
Promote?
Promote motor function and minimize fatigue . Have the
patient complete important tasks in the morning since
they get tired in the night ! .
ALS is progressive irreversible upper and lower motor neuron loss.
Priorities
- AIRWAY Drooling and regurgitation - Suction and reposition pt.
- Pneumonia risk due to aspiration + Resp failure
Amytrophic Lateral Sclerosis :
what is it? Priority? Nursing -Optimize mobility + social interactions
Considerations?
Considerations:
- these patients are not impaired cognitively. Speak to them
normally and give them time to respond.
- corticosteroids : acute flares
- limit salt intake (fluid retention can occur and make things worse)
M.S.: Pharm management? - taper off !
- immunosuppressants
Terms in this set (108)
Tests LOC of patient.
Glasgow Coma Scores
Scale: what is it?
scores? highest: 15 (fully
when to call HCP? conscious) lowest: 3
(borderline dead)
Danger: less than 8
intubate
call HCP if there is ANY change AT ALL in the pt GCS !
Bell's Palsy is when one side of the face becomes paralyzed.
Symptoms eventually resolve on their own.
, We want to rule out stroke
Bell's Palsy: what is it? what do
we want to rule out? nursing
priorities ? Nursing Care
- aspiration risk (tell the patient to chew on the unaffected side)
- corneal abrasions bc eyes can't close. Tell the patient to
use eye drops or an eye patch.
Bell's Palsy
- face drooping ONLY
- symptoms resolve on their own usually
Bell's Palsy vs. Stroke: what are
the differences?
Stroke
- OTHER SYMPTOMS IN ADDITION TO FACIAL DROOPING:
slurring speech, vision change, weakness.
- damage can be PERMANENT
, Trigeminal neuralgia (anything algia means pain) is a brief
acute facial pain/ twitching. The pain can be described as
sharp or "knife-like"
Triggers: chewing, brushing teeth, hot/cold, touch. Because of
Trigeminal Neuralgia: what is
this, patient may avoid hygiene and eating!
it? describe the pain? what are
the triggers and what can
this lead to? Nursing care? Nursing:
- limit triggers during acute phases.
- adequate hydration + nutrition
G.B.S is a rare destruction/inflammation of the nerves
accompanied by ascending muscle weakness + paralysis.
The autonomic nervous system is
impacted. Priorities:
- Airway + breathing (due to ascending paralysis/resp deprerssion)
- BP (can cause orthostatic hypotension) + HR
Guillan Barre Syndrome: what
is it? Which system is affected? - prevent immobility
What are the priorities?
Chronic autoimmune disease of disruption in neuronal
signals (myelinated). Triggers: fatigue, overexertion,
stress, hot temp ( avoid hot showers )
Diagnosis:
Multiple Sclerosis: what is it?
Triggers? diagnosis? - takes a long time
- no one knows why. Vit D deficiency is suspected
(higher incidences in people farther from equator/sun)
- IgG and lesions on MRI can help diagnose
M.S. affects patient's mood causing depression, anger, and
euphoria. Tell pt that these are normal side effects and that
we will help them through it. M.S. also affects GI/GU +
sexual dysfunction.
Nursing Considerations for
Multiple Sclerosis : what does
, it affect and what should we tell Our priority is ADLs for our patient!
the patient? Priority?
Promote?
Promote motor function and minimize fatigue . Have the
patient complete important tasks in the morning since
they get tired in the night ! .
ALS is progressive irreversible upper and lower motor neuron loss.
Priorities
- AIRWAY Drooling and regurgitation - Suction and reposition pt.
- Pneumonia risk due to aspiration + Resp failure
Amytrophic Lateral Sclerosis :
what is it? Priority? Nursing -Optimize mobility + social interactions
Considerations?
Considerations:
- these patients are not impaired cognitively. Speak to them
normally and give them time to respond.
- corticosteroids : acute flares
- limit salt intake (fluid retention can occur and make things worse)
M.S.: Pharm management? - taper off !
- immunosuppressants
