Summary
Summary NURB 3130 Exam 4 Study Guide
- Course
- NURB 3130
- Institution
- Northwestern State University Of Louisiana
This is a comprehensive and detailed study guide on Exam 4 for NURB 3130. *An Essential Study Resource!! Here for YOU!!
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Exam 4 SG3130
Neuro
Function of the brain
- Autonomic nervous system:
o Functions to regulates activities of internal organs and to maintain and restore
internal homeostasis
o Sympathetic nervous system
“Fight or flight” responses
Main neurotransmitter is norepinephrine
o Parasympathetic nervous system
Controls mostly visceral functions
o Regulated by centers in the spinal cord, brainstem, and hypothalamus
- Neurotransmitters 1947
o Communicates messages from one neuron to another or to a specific target tissue
o Neurotransmitters can
potentiate, terminate, or modulate a specific action or
can excite or inhibit a target cell
o Many neurologic disorders are caused by an imbalance in neurotransmitters
- Neurologic Assessment
o Pain
o Seizures
o Dizziness (abnormal sensation of imbalance or movement) and vertigo (illusion of
movement, usually rotation)
o Visual disturbances
o Weakness
o Abnormal sensations
o Past health, family, social history
, o Consciousness and cognition: mental status, intellectual function, thought content,
emotional status, language ability, impact on lifestyle
o Cranial nerves
o Motor system: muscle size, muscle tone and strength, coordination and balance,
Romberg test
o Sensory system: tactile sensation, superficial pain, temperature, vibration and
position sense (proprioception)
o Reflexes: DTRs, biceps, triceps, brachioradialis, patellar Achilles, superficial,
pathologic, plantar (Babinski)
- Gerontologic Considerations
o Important to distinguish normal aging changes from abnormal changes
o Structural and physiologic changes
o Motor and sensory alterations
o Temperature regulation and pain perception
o Determine previous mental status for comparison. Assess mental status carefully
to distinguish delirium from dementia
- Diagnostic Evaluations – look at chart in Moodle and pg. 1970 65-4
o Computed tomography (CT)
o Positron emission tomography (PET)
o Magnetic resonance imaging (MRI)
o Quality/Safety Nursing Alert – page 1966
o Cerebral angiography
o Myelography
o Noninvasive carotid flow studies
o Transcranial Doppler
o Electroencephalography (EEG)
o Electromyography (EMG)
o Nerve conduction studies, evoked potential studies
o Lumbar puncture with analysis of cerebrospinal fluid
Management of Patients with Neurological Dysfunction
- Altered LOC
o Level of responsiveness and consciousness - most important indicator - patient's
condition
o LOC – continuum…normal alertness/full cognition to coma
o Altered LOC - not the disorder…result of a pathology
o Coma: unconsciousness, unarousable unresponsiveness
o Akinetic mutism - unresponsiveness to environment; no movement or sound but
may open eyes
o Persistent vegetative state – no cognitive function but has sleep–wake cycles
o Locked-in syndrome - inability to move or respond except eye movements due to
a lesion affecting the pons
- Nursing Process with altered LOC: PATIENT CARE
o Verbal response – AAO? – document if they’re intubated
o Alertness
, o Motor Response (posturing)
o Respiratory status
o Eye signs
o Reflexes
o Table 66-1, page 1976 – Assessment – unconscious patient
o Quality and Safety Alert – Restraints – page 1977
Avoid at all cost because anxiety will increase inc ICP
o Quality and Safety Alert – Body Temp– page 1977
Never check body temp orally—preferred rectal, tympanic, core
o If they aren’t verbally responsive, check pain
Decorticate – move toward the core
Decerebrate – move away from the core
Flaccidity is the worst—no response
- Nursing Process altered LOC: DIAGNOSIS
o Ineffective airway clearance
o Risk of injury
o Deficient fluid volume
o Impaired oral mucosa
o Risk for impaired skin integrity and impaired tissue integrity (cornea)
o Ineffective thermoregulation
o Impaired urinary elimination and bowel incontinence
o Disturbed sensory perception
o Interrupted family processes
- Potential Complications
o Respiratory distress or failure
o Pneumonia—CPT, suction
o Aspiration
o Pressure ulcer—Positioning
o Deep vein thrombosis (DVT)—ROM, SCDs
o Contractures—may need splints
- Nursing Interventions altered LOC
o Major nursing goal—compensate for the loss of protective reflexes—total patient
care
o Protection…maintaining the patient’s dignity & privacy
o Maintaining an airway/distress/aspiration/pneumonia
o Frequent respiratory monitoring
Positioning…prevent obstruction of upper airway, removal of secretions—
HOB elevated 30 degrees; lateral may be necessary; caution when feeding;
IS; cough/turn/deep breathe
Suctioning, oral hygiene, CPT
o Maintaining tissue integrity
Frequent skin assessment…especially areas with higher potential for
breakdown
Frequent turning - schedule
, Contractures - positioning…correct body alignment; passive ROM; use of
splints, foam boots, trochanter rolls, specialty beds
DVT precautions
Eye care measures
Artificial tears
Protect eyes…use eye patches cautiously - cornea may contact
patch
Oral care – frequently
o Maintaining fluid status
Assess fluid status…tissue turgor, mucosa, labs data, I&O
IVs, tube feedings/fluids
o Maintaining body temperature
Monitor body temp
Environmental conditions
If temperature elevated…limit bedding, acetaminophen, hypothermia
blanket, cooling baths
Quality and Safety Alert - temperature
o Promoting bowel/bladder function
Assess…urinary retention/urinary incontinence
May need intermittent catheterization
Bladder training program
Assess for abdominal distention, potential constipation, bowel
incontinence…Monitor BMs
Promote elimination…stool softeners, glycerin suppositories, enemas
Diarrhea is potential problem…from infection, medications, hyperosmolar
fluids
o Sensory stimulation/communication
Talk to/touch patient…encourage family
Maintain normal day/night pattern of activity
Orient frequently
Programs for sensory stimulation
Provide family support; frequent updates; referral groups
- Seizure Disorder
o Abnormal episodes of motor, sensory, autonomic, or psychic activity (or a combo)
resulting from a sudden, abnormal, uncontrolled electrical discharge from cerebral
neurons
o Classification of seizures
Focal: originates in one hemisphere of the brain
Generalized: occur in and engage bilaterally
Absent seizures and Tonic- Colonic
Unknown: epilepsy spasms
“Provoked” related to acute, reversible condition
Temperature related, Na levels, CNS infection
- Plan of Care for a Pt Experiencing a Seizure
o Observation/documentation…S&S before, during, after
o Chart 66-4: (Page 1998) Care of the Patient During/After a Seizure
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