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IU NUR 435 - Exam 3 Study Guide

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Exam 3 Study Guide- Differences betweeno Hyperflexion: Forward motion of heado Hyperextension: Backward extension of heado vertical compression: caused by a compressive downward forceo rotational spinal cord injuries: quick turning of the spine- Basilar skull fractureso Fracture of the base of the skullo Signs & symptoms: raccoon eye, battle’s sign, CSF fluid from the ears and the nose (Hallmark sign)o Glucose will be detected in CSFo Avoid Insertion of the NG tubeo Assessments: Look for the fluids from the nose and ears, assess for battle’s sign and raccoon eyes- Spinal cord injurieso EMERGENCYo Halo traction: maintains cervical stabilization keeps the spine in alignment Assessments: Pin site for infection, ABC’s, vitals, motor function/sensationlevel, I&O, bowel sounds, pain Complications: pin site infections, skin breakdown, swallowing problems, pin site loosening (bad because it messes with alignment)o Nursing interventions: ABC, log roll when moving, restore BP, IVF, Vasopressors, Inotropes, test for sensation/motor function, suction equipment at the bedside, facilitate cough effectiveness, passive ROM, maintain spinal immobilization and stabilization, pin site care (1x per shift)o Teaching: s/s of autonomic dysreflexia, skin care, s/s of respiratory distress, dysphagia, pin site and vest care- Neurogenic shock o Sudden loss of autonomic nervous system function: Involuntary functionso Signs & symptoms: vasodilation, bradycardia, hypotension, labile temp, warm dryskin, hypovolemia, myocardial ischemia, Decreased LOC, metabolic acidosis, dependent edema and lactate accumulation.o Caused by: SCI, high doses of barbiturates, strokes, and anesthesiao Treatment: fluid, vasopressors, atropine- Spinal shocko Sign & symptoms: occurs immediately after injury, temporary loss of all spinal reflexes- Autonomic Dysreflexiao Causes: pain, distended bladder, rapid temp changes, infection, full rectumo Symptoms: intense headache, hypertension, bradycardia or tachycardia, diaphoresis, and flushing above level of injury.o Treatment: remove causative agent- Head injurieso Opened o Closedo Glasgow coma scale <3 is very bad <8 we intubateo 3 classifications: Mild, moderate, and severeo Signs & symptoms: Severe headache, nausea, vomiting, restlessness, irritability, LOC, dilated or pinpoint nonreactive pupils, and seizures.o Assessments: Glasgow coma scale, check for skull fracture and cervical spine injury, neuro assessment, assess for localized pain, be alert for CSF drainage fromears and nose (basilar skull fracture)o Nursing interventions Think about priority: RESPIRATORY STATUS – hypoxia if untreated can leadto brain injury or death, assess for cranial nerve functions, PERRLA, assessfor bilateral sensory motor responses- TBIo Signs & symptomso Assessmentso Nursing interventions- Craniotomyo Removal of non-working part of the brain, relieves ICP, and removal of tumorso Piece of skull is placed in blood bank or abdomeno Interventions: Dexamethasone, IVF, VTE prophylaxis, neutral position, head of bed 30-45 degrees, stool softenerso Teaching: Tapering of steroids, monitoring glucose, antileptic meds, fall prevention, wearing a hat, mouth care from chemo- Increased ICPo ICP >15o Signs & symptoms: Progressive confusion, lethargy, sluggish reaction of eyes withovoid shape, and contralateral motor weakness, severe headaches, Cheyne stokes breathing, decerebrate and decorticate posturing, seizureso Assessments: Neuro every 1-2 hours, Glasgow Coma Scale, look for signs and symptomso Interventions: Seizure precautions, Increase HOB 30 degrees, neutral body position, patent airway, report any CSF leaks, limit visitors, calm environment, q2h turns, hearing is the last sense effected by head injuries so explain what you are doingo Meds: Mannitol, Barbiturates, Phenytoin (for seizures), Morphine, Fentanyl, 3% NS- Blood transfusion o Labs: Lower than 4 million RBC’s is low, CBC, Lower than 20,000 plt give plateletso Interventions: 2 RN process, 20-gauge access, Normal saline, vitals baseline and then 15 minutes, Blood must be administered in less than 4 hourso Reactions Hemolytic- Flank pain, fever, chills, hypotension- Stop infusion give NS- call provider Febrile- Temp increase of 2 degrees, chills, headache, chest pain- Stop transfusion, administer antipyretics, restart transfusion Allergic- Itching, hives, facial flushing, anxiety, dyspnea- Stop transfusion, Administer antihistamines, and restart transfusions Circulatory overload- Headache, JVD, dyspnea, edema, and increased BP- Stop transfusion, elevate HOB, administer diuretics/oxygen, restarttransfusion slowly- DICo Causes: Sepsis, burns, crush injuries, abruptio placentae, and other severe traumaso Signs & symptoms: bleeding from every orifice o Nursing interventions: treat underlying cause, administer blood/plt/FFP/cryoprecipitate which has factor 5, Splenectomy- HITo Signs & symptoms: Easy bruising, bleeding from the nose gums and GI tracto Assessments: look for Ecchymosis, petechia, purpura, frank bleedingo Interventions: Minimize blood loss from venipunctures, avoid IM injections, provide a safe environment, no but stuff, use manual blood pressure cuff- Cobalamin deficiencyo Signs & symptoms: visual disturbances, peripheral neuropathy, altered mental status, paresthesia’s, tachycardia, tachypnea, altered mental status, parasthesias,tachycardia, tachypnea SOB, dizziness, and fatigueo Dietary sources: meat, seafood, eggs, and dairy o Weekly B12 injections or oral route- Thrombocytopeniao Reduced number of Platelets <150o Signs & symptoms: bleeding , petechia, purpurao Assessments: Assess for bleeding,o Interventions: platelet transfusion if platelets are less than 20, advoid sex with platelets less than 50, treat the causation- Polycythemiao Teaching: Raise their legs, drink 3 L of fluid a day, eat frequent small meals, raise the head of the bed, stop climbing mountains, wear loose clothing, know s/s pf a dvt, routine exercise, regular lab tests, and genetic testing- Chemotherapyo Assessments: excess the site for extravasation and infiltration, excess for evidence of infection, assess lab values, assess skin for irritation, mouth sores, s/sof infection, fevero Labs: neutrophils, wbc’s (<4000), absolute neutrophil count o Interventions: neutropenic precautions (change water daily), avoid large crowds, private rooms, restrict ill visitors, place a mask on the patient during transport.o Teaching: proper hand

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