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NUR 2755 / NUR2755 Exam 3: Multidimensional Care IV / MDC 4 Exam 3 Review (2021/2022) Rasmussen
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NUR2755 Multidimensional Care IV / MDC 4 Exam 3 Review
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Seizures Phases
o Ictal phases: moving in patient
o Tonic-clonic: 2-5 minutes, starts with tonic then clonic, may bite tongue or become
incontinent. May be preceded by an aura.
o Tonic: Few seconds or several minutes, stiffening muscles, LOC, arrythmias, apnea,
vomiting, incontinence, salivation
o Clonic: muscle contractions and relaxation. May last several minutes
o Myoclonic: brief jerking/stiffening of extremities, one area or groups of muscles, last a few
seconds
o Atonic: loss of muscle tone, flaccid, results in falling, lasts seconds followed by confusion.
o Postictal phase: confusion, sleepiness, agitation
First thing you want to do as the nurse à reorient the patient
o Status epilepticus: lasts longer than 5 minutes, back-to-back seizing, medical emergency
Can be caused by patients that abruptly stop taking medications
Benzodiazepine first drug for this (Diazepam/Lorazepam)
Treatments
o Antiepileptic drugs
Carbamazepine Oxcarbazepine (Oxtellar/
(Carbatrol, Tegretol) Trileptal)
Phenytoin (Dilantin, Lamotrigine (Lamictal)
Phenytek) Gabapentin (Gralise,
Valproic acid (Depakote) Neurontin)
Topiramate (Topamax)
o Phenobarbital
o Dilantin causes gum overgrowth
o Keep taking these drugs even in the absence of seizures, DO NOT STOP THEM
o Procedures:
vagal nerve stimulator
craniotomy to remove brain tissue causing seizures
Interventions- lower patient to the floor, turn on side, loosen clothing, note onset/duration, DO
NOT HOLD PATIENT DOWN DURING SEIZURE
Post-seizure: ABCs, check vitals, reorient patient, maintain side lying position, suction/oxygen if
needed, perform neurological status check, allow rest, determine presence of aura to indicate
origin, determine triggers
Seizure precautions: pad bed rails, keep bed rails up, suction nearby, IV inserted
Diagnostics
o CT-scan
o EEG- no caffeine the night before
o MRI
Parkinson’s
S/S
o Fatigue
o Stooped posture – dopaminergic problem
o Muscle rigidity
o Resting tremors
o Propulsive forward shuffling gait
, o Akinesia/bradykinesia
o Mask-like expression
o Drooling
o Dysphagia
Treatment- used to treat symptoms and increase mobility
o Levodopa/carbidopa: turns into dopamine and minimizes muscle rigidity
o Dopamine receptor agonists: monitor for orthostatic hypotension, dyskinesia, hallucinations
o Catechol O- Methyltransferase (COMT inhibitors): decrease breakdown of levodopa (last
longer in the system), monitor for dyskinesia/hyperkinesia when taken with levodopa.
Assess for diarrhea. Dark urine is normal
o Monoamine oxidase type B (MAO B) inhibitors: inhibits dopamine, avoid tyramine foods
which can cause hypertensive crisis
o Anticholinergics: these are decreased levels of acetylcholine in PD patients. Monitor for
anticholinergic effects such as dry mouth, constipation, urinary retention, confusion
o Antivirals: stimulate release of dopamine and prevent reuptake
Procedures: deep brain stimulation- electrode implanted in thalamus. Decreases tremors and
involuntary movements.
Monitor for infection or strokes
Nursing interventions
o Monitor swallowing
o I&O
o Thicken food
o Sit upright to eat 30 degrees or higher (avoid aspiration)
o Have suction available
o Assist with ROM exercises
o Assist with ADLs
o Fall precaution
o Allow extra time to complete tasks
o Encourage rocking back and forth to get up from chair with bradykinesias
Autonomic Dysreflexia (Hyperreflexia)
Common in spinal cord injuries, high thoracic, low cervical
S/S
o Extreme hypotension, severe headache, blurred vision, diaphoresis, sudden increasing blood
pressure
Treatment
o Prevention
Patient education
o Bowel and bladder training to prevent bladder distention
o Assessment of indwelling catheters
o Stool softener
o Frequent catheterization
Interventions
o Sit up to decrease BP, notify provider, monitor for signs of severe hypertension or bradycardia,
administer anti-hypertensives (nitrates, hydralazine), determine and treat cause
Distended bladder is the most common cause (kinked/blocked indwelling catheter,
urinary retention, urinary calculi).
Insert catheter for distended bladder or check if current one is kinked
, Remove fecal impaction
Remove tight clothing
Assess for injuries (lower extremity fracture, kidney/bladder infection)
Spinal cord injuries with Halo
No driving
Assess pins for infection
Assess skin for breakdown
MVC patients get airway with C-spine control
Alzheimer’s disease
S/S
o Stage 1 mild- forgetfulness, short-term memory loss, mild cognitive impairment
o Stage 2 moderate- begin to see personality manifestations such as disorientation, anger,
assistance with ADL’s, incontinence, wandering, visuospatial deficits
o Stage 3- severe- bedridden, verbal/motor skills lost, dysphagia
Treatment (no cure, medications can manage symptoms)
o Donepezil (Aricept)
o Cholinesterase inhibitors
o Psychotropic drugs
o Namenda (memantine)- drug of choice. Slows pace of deterioration
o SSRI’s (Paxil, Zoloft), not tricyclics (Elavil)
Will cause confusion, urinary retention, constipation
Interventions
o Have a routine
o Imitate home environment as much as possible (they react to a change in environment)
o Exercise during the day to improve sleep
o Complimentary therapies
Family anxiety concerns expressed
o Redirect and distract
o Adult day care
o Dementia care options
Neuro assessment - Glasgow coma scale
Performed to calculate eye, best motor, verbal response. Patients’ response to select stimuli is graded
o 15+ is good, 8 or less is comatose, 3 or less in unresponsive
o Decerebrate posturing extended supination and dorsiflexion
“Want a bowl of soup? Palms up”
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