All Examplars + CP

Complication

Name a complication of cerebral palsy.

1. Difficulty with ambulation 

2. Decreased nutrition

3. Respiratory issues

4. Difficulty speaking

Difficulty with ambulation

Cerebral Palsy patients have difficulty ambulating related to spasticity, muscle weakness and muscle rigidity.

Pathophysiology

What is cerebral palsy

A non progressive disorder that affects posture, body movement and muscle coordination

Manifestations

A nurse is assessing a 7 month old infant. The mother states “My baby is having a hard time sitting up. When he does sit up, there is always support behind him, or I help him.” The nurse suspects what condition for the infant?

Rationale:

Cerebral Palsy

Rationale:

Normal Child Milestone

• Head control = 2-3 months

• Sitting unsupported = 6-9 months

• Walking = 12-28 moths

A 7 month child should be able to sit unsupported according to normal developmental milestones. The nurse should suspect possible cerebral palsy

Risk Factors

What are the risk factors for a child to develop cerebral palsy

• structure abnormalities

• ischemia or hypoxia in prenatal, perinatal or postnatal stages

• infection (strep)

• preterm

• child abuse (head trauma)

Manifestations

What manifestation would parents first observe in their children when it comes to possible cerebral palsy

Rationale:

tonic bite and feeding difficulties

Rationale:

CP causes poor control of muscles. The infant does not have voluntary control of the muscles in their mouth

Manifestations

A mother fells and bruised her stomach. The mother states that she is worried about CP in her unborn child. The mother asks “what signs should I look out for if I suspect CP?” The should respond with

Rationale:

the most significant signs of CP are

• Ataxia = unsteady gait

• toe walking

Nurse Intervention

A nurse is speaking with the parents of a child suspected of CP. Parents explain significant signs of CP. The parents ask “what can we do to help our child with this condition” What is the nurses response.

Rationale:

Start the child in early stimulation programs

Rationale:

The use of therapeutic modalities such as physical therapy, occupational therapy, and speech therapy will be essential in promoting mobility and development in the child with cerebral palsy. The earlier the treatment begins, the better chance the child has of overcoming developmental disabilities

Treatment

A child with with CP is taking baclofen for their muscle spasticity. What education should the nurse provided about this drug

Rationale:

Don’t stop the drug abruptly

Rationale:

Stopping the drug abruptly can cause painful spams to return

Pathophysiology

What is hydrocephalus

An excessive accumulation of CSF in the ventricles of the brain causing them to swell 

Manifestations

What are the three common sigs of hydrocephalus in a child

• enlarged head

• sun setting eyes

• poor feeding

Nurse Interventions

A child is finished their surgery for the ETV. What should the nurse do to prevent ICP

Rationale:

Lay the child on their side, on the opposite side of where they got the shunt

Nurse Intervention

A nurse is caring for a pediatric patient and notes bulging fontanelles . In addition, the nurse notes sun setting eyes, vomiting, lethargy, and irritated. What should the nurse suspect and what should the nurse do

Rationale:

• signs if ICP

• contact the provider

Rationale:

bulging fontanelles, sun setting eyes, vomiting, lethargy, and irritated are signs of increased ICP. Doctor should be notified due to emergency

Nurse Intervention

A nurse is caring for a child post ETV shunt. What signs should the nurse look for when it comes to monitoring signs of potential ICP from a blocked shunt.

pupillary dilation

Nurse Education

A nurse is providing education to the parents of an infant who has finished ETV surgery. What should the nurse educate when it comes to the infant and the shunt

• do shunt care to prevent infection

• dont elevate the head of the bed to reduce ICP risk

• keep the child flat for 24-48 hours to reduce fluid shifts

Manifestations

A nurse is caring for a patient with suspected meningitis. The nurse helps the patient flex their neck upwards. When the neck is flexed, the knees and the hips also flex. What would the nurse call this maneuver

Brudzinski Sign

Manifestations

A nurse is caring for a patient with suspected meningitis. The nurse helps the patient extend their leg. The patient complains of pain. How would the nurse interpret this maneuver

Kernig’s Sign

Pathophysiology

inflammation of meningeal layer. The infection spreads vias the bloodstream and and can lead to ICP

Meningitis

Patho

A nurse is explaining the two main causes of meningitis. What should the nurse say?

• strep pneumoniae

• neisseria meningitidis

Risk Factors

A nurse is education teens about demographics who are an increased risk for contracting meningitis. What should the nurse say?

• crowded areas

• college dorms

• military dorms

All carry the increased risk to develop meningitis

Diagnostics

A nurse is carrying for a patient with suspected meningitis. What might the nurse suggest to obtain a definitive confirmation to meningitis

• CT

• LP

Rationale

the lumbar puncture pulls the CSF and uses a gram stain to detect pathogen that causes meningitis

Nurse Interventions

A nurse performs a positive brudzinski sign and suspects possible meningitis. What precautions should the nurse take take during the care of the patient

Rationale:

• isolate them immediately

• use droplet precautions

Rationale:

pathogen is highly contagious

Nurse Education

A nurse is providing meningitis vaccination information to the parents of a pre-teen boy. What information should the nurse provide about the vaccine

Educate to vaccinate at around 11-12 years old and again at 16

Treatment

Name:  Rifampin, Ciprofloxacin, Ceftriaxone, ampicillin, Penicillin G  Used for treatment of meningitis Nurse Consideration:

Name:  Rifampin, Ciprofloxacin, Ceftriaxone, ampicillin, Penicillin G  Used for treatment of meningitis Nurse Consideration:  Must start med regimen within 24 hours after exposure  Delaying the antibiotics reduces its effectiveness   Ampicillin and cefotaxime is for pts < 6 weeks of age  Vancomycin, cefotaxime , rifampin is for pts > 6 weeks of age

Nurse Education

A nursing student is caring for a patient who is brain dead. The nurse following the rules of 100, and making sure the patient is ready for organ procurement. What places a patient un able to donate their organs

• HIV

• Hep B

• active TB

Nurse Education

A nursing student is asking about the Rules of 100. How can the nurse best explain this process

Rationale:

• Use the Rule of 100

  • O2 = 100

  • Urine output = 100 ml / hr (call the doctor if it drops)

  • BP = 110 

  • Temp = 100 (97 to 102)

Rationale:

these interventions allow for the organs to stay viable before procurement

Nurse Interventions

A patient has been declared brain dead. Who must be contacted if the family members what more clarification on the status of their brain dead relative

Organ Procurement organization

Manifestations

A nurse is caring for a patient who is brain dead. What manifestations might the brain nurse see upon inspection

• Pt cant respond to command

• Pt is flaccid 

• Pupils are unreactive 

• No occulocephalic reflex 

• No stimulation to supra-orbital stimulation 

• No ocular vestibular reflex 

• No gag reflex 

• No spontaneous respiration

Nurse Interventions

A nurse is assessing a child with a brain tumor. The nurse palpates the fontanelles and notices bulging. What do these signs indicate and what should the nurse do

indicates increased ICP and to contact the HCP

Rationale:

An emergency

Treatment

A nurse notes ICP in a child with a brain tumor, what should the nurse admin

Rationale:

dexamethasone

Adverse Effects

• hyperglycemia

• hypokalemia

• muscle weakness

Rationale:

a med that can lower ICP

Treatment

A child is recovering from an operation to remove their brain tumor. The nurse is worried about cerebral edema. What medication should the nurse anticipate the HCP to order

• mannitol

• hypertonic dextrose

Rationale:

reduces cerebral edema that can turn into ICP

Nurse Interventions

A nurse is caring for a post op child who has had brain tumor surgery. The nurse is concerned about CSF leaks. What can the nurse do to reduce the risk of leakage

• provide a quiet non stimulating room '

• check dressing and nares for CSF leaks

• lay flat

Manifestation

A nurse is caring for a post-op child. The nurse suspects brain herniation. What signs might the nurse see?

• crushing’s triad

• body temp changes

• nuchal rigidity

• sluggish pupils

Manifestations

A nurse assess a child an notices that they do not have PERLA, but a fixed and a dilated pupil. How should the nurse interpret this

a neurosurgical emergency

Areas of the brain and how they are affected by a brain tumor

Frontal Lobe
Parietal Lobe
Temporal Lobe
Occipital Lobe
Cerebellum
Brainstem

Frontal Lobe	planning, problem solving, movement, emotion, speech
Parietal Lobe	5 sense, pain and space perception
Temporal Lobe	hearing, language, memory and emotion
Occipital Lobe	vison, color, distance
Cerebellum	voluntary movement and balance
Brainstem	HR, RR, BP

Pathophysiology

What is traumatic brain injury

an injury to the skull or the brain that is severe enough to interfere with normal function

Pathophysiology

What is coup and counter coup

a serious traumatic brain injury where the front of the brain is damaged from the direct impact and the opposite side hits the side of the skull

Pathophysiology

why is counter coup more severe than the initial site of impact

Rationale:

the jerking backwards of the brain hits the back part of the skull. MVA, falls and shaking infant syndrome are increase risk factors to counter coup

Rationale:

increases the risk for hemorrhage

Pathophysiology

What is the Monroe Kellie hypothesis and how is that connected to ICP

The cranial vault:

• brain

• blood

• CSF

1/3 will increase in volume, then the other two must decrease in volume or there will be an increase in ICP

Complications

what are the two complications a skull fracture cause

• cerebral hypoxia

• ischemia

Nurse interventions

A nurse suspects a basal skull fracture and clear fluid is leaking from the pts ears. What diagnostics can the use to determine CSF possibility

check with a glucose monitor or halo test

Manifestation

A nurse assess bruising over the mastoid process of the ears, what is the condition called

battle sign

Diagnostic

A patient came in with a possible skull fracture and might have a consussion, what diagnostic tool might the nurse use to determine the extent of the fracture

A CT scan (first line)

MRI

Glasgow scale = 15 is best

Nurse Education

A patient that suffered a skull fracture is about to go home. What education should the nurse provide to the patient and the family

• educate on the symptoms to watch out for

• watch the patient for 24-48 hours after the brain injury

  • The patient can sleep but wake them every 3-4 hours in the first 24-48 hours

• avoid screen time for a few days

• avoid aspirin and ibuprofen (acetaminophen is okay)

• avoid heavy weight lifting

Manifestations

A patient had a head injury and is entering the late stages of the injury. The nurse suspects Crushing Triads. What would the nurse see upon presentation

• widened pulse pressure (high systolic/low diastolic BP)

• bradycardia (low heart rate)

• irregular respiration

Manifestation

decorticate

Manifestations

decerebrate

Pathophysiology

what is a epidural hematoma

Manifestations

Rationale:

bleeding between the dura and the inner surface of the skull

• unconscious with brief lucid intervals

• headache

• NV

Rationale:

these bleed is arterial in nature and bleeds FAST

Pathophysiology

what is a SUBDURAL hematoma

Manifestations

Rationale:

bleeding between the dura and the arachnoid layer of the meninges

• decreased LOC

• headache

• ipsilateral pupil dilation

Rationale:

venous bleed and a slow bleed

Pathophysiology

what vertebra are mostly involved in spinal cord injuries

• C1-C5

• T12

• L1

Pathophysiology

What are the two types of spinal cord injuries

Rationale

• primary

• secondary

Rationale:

Primary- is direct physical trauma to the spinal cord

secondary- after a primary injury, the injury becomes on going and progressive

Manifestation

what are the symptoms of a spinal cord injury that develops into spinal shock

• ↓ DTR

• Spinal reflex and sensation

• flaccid apparency below the level of injury

Nurse intervention

A nurse is caring for a patient who has

HR: 54

TEMP: 97 at 11 am , 99 11:30 am, 100 at 12 pm

BP: systolic of 87

How should should the nurse interpret these findings and what should she do

Rationale:

these are signs of neurogenic shock and should contact the HCP

Pathophysiology

Why is a secondary spinal cord injury dangerous

Rationale:

edema can form within 24 hours and create permeant tissue damage

Which action should the nurse recognize has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury?

 

1. Assessment of respiratory rate and effort

2. Cardiac monitoring for bradycardia

3. Administration of low-molecular-weight heparin

4. Application of pneumatic compression devices to legs

Assessment of respiratory rate and effort

Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient’s respiratory function

Manifestations

What type of paralysis can be noted if there is damage C4. C6, T6 areas of the spinal cord

• C4 = complete paralysis below the neck

• C6 = partial paralysis of hand and arms

• T6 = paralysis below the chest

Treatment

What medications can be given to pts who have low HR and low RR and have a spinal cord injury

atropine

Nurse Interventions

A nurse is caring for a spinal cord injury patient and is using a Halo Brace. What should the nurse to reduce the risk of infection

provide pin care everyday

Rationale:

the screws are entering the skull via the skin. Break in skin and bone integrity can lead to infections. Care is needed to prevent this

Pathophysiology

what is autonomic dysreflexia

a life threatening condition that can result from spinal cord injuries that affect T6 or higher

Risk Factor

Why is damage to the T6 area of the spinal cord important to understand the triggers of autonomic dysreflexia

Rationale:

T6 is the area of the CNS the sends and receives info to signal to the body of full bladders or bowel impactions.

Rationale:

Damage to the T6 causes the body to not feel when the bladder is full or the bowels are impacted. Full bladder or bowels is the biggest trigger for autonomic dysreflexia

Nurse Interventions

A nurse is caring for a patient who has a T6 spinal cord injury. The nurse take a BP of 160/ 88, HR of 34 and assess the patients bladder- the bladder is hard and distended upon palpation. What is the primary intervention (3 steps)

Rationale:

1. raise the HOB 45'

2. Contact the HCP

3. Do a straight catherization

Rationale:

Damage to the T6 causes the body to not feel when the bladder is full or the bowels are impacted. Full bladder or bowels is the biggest trigger for autonomic dysreflexia. A straight catheterization with remove the built up urine reducing the risk that comes with a full bladder. Elevating the HOB helps reduce the pressure

A BP of 20-40 mm Hg above the baseline + bradycardia (30-40 bpm) + full bladder = autonomic dysreflexia S/S

Treatment

If a patient is experiencing automatic dysreflexia, what medications are given

Rationale:

Nitroglycerin Paste

Rationale:

Nitro will decrease the elevated blood pressure from the autonomic dysreflexia crisis

Manifestations

what are the manifestations of autonomic dysreflexia

• hypertension

• diaphoresis above the injury

• bradycardia

Nurse Interventions

A nurse has assessed for bladder distension and bowel impaction. The nurse notes no distention and impaction. What other nursing interventions should the nurse do to determine triggers to autonomic dysreflexia

assess for skin breakdown, tight clothes and laying on the call light

Pathophysiology

what is a fracture and how are they classified

• a disruption or break in bone continuity

• Classification

  • Complete or incomplete

  • open or closed

  • stable or unstable

Pathophysiology

Describe the 6 types of fractures

• transverse = straight across

• spiral =

• greenstick = split or bent

• comminuted = crumbled

• oblique = across / down the bone

• pathologic = diseased bone fracture

Manifestations

what are the manifestations of a bone fracture

• edema / swelling

• pain

• muscle spasm

• deformities

• confusion

Risk Factors

what are the risk factors to fractures

Rationale:

• elderly

• post menopause

• high risk activities

Rationale:

post menopausal women are more at risk due to the development of osteoporosis. As a result, their bones are weaker and will break.

Pathophysiology

what are the stages of bone healing

Rationale:

1. fracture hematoma- a blood clot forms at the fracture

2. granulation tissue-

3. callus formation- C.T. forms a callous at the end parts of the fracture

4. ossification- the bone hardens

5. consolidation and remodeling- the callous is reformed and the bone has shape again

Nurse Interventions

why is fracture reduction like manipulation, reduction and traction devices important nursing interventions for fractures

these intervention keep the bone aligned properly

Nurse Interventions

Give examples of fracture immobilization tools / interventions

• external cast = a physical cast placed over the fracture

• internal or external fixation = using pins to immobilize the fracture

• maintenance traction = (bucks traction) used in the hospital to immobilize the fracture

Nurse Interventions

What interventions are needed if a patient has open fractures

Rationale:

• surgical detriment

• tetanus / antibiotics

Rationale:

fractures that have open wounds are at increase risk for infection. Cleaning and admin of drug therapy early reduce the risk of infection development.

Nurse Interventions

After a fracture has be immobilized. what should nurse do to prevent complications

Rationales

• The nurse should do neuro checks every hour

• turn every 2 hours

• keep the cast dry

• elevate above the head

Rationale:

1. to make sure they don’t have nerve damage and have good blood flow

2. to reduce pressure injuries risk

3. protect skin integrity / infection

Treatment

what is a skin traction boot

Rationale:

A skin traction boot is a immobilization device were weights are hanging off the end of the bed.

Rationale:

• the weights must never touch the ground because the tension is what helps immobilize and align the fracture to heal properly

• it also helps reduce muscle spasms

Treatment

A nurse just finished obtaining report on a patient who fell 6 stories. The patient has a fracture on the right femur. The nurse is notified that the patient is on a Skeletal Traction Bed Frame. An order is placed for 10lbs to hang from the traction device. The nurse notes that the patient’s device only has 2lbs. What should the nurse do?

Rationale:

Contact the HCP

Rationale:

In order for the traction device to work, tension must be created. Improper weight will reduce said tension and prevent the immobilization/ alignment needed to heal the fracture. Contact the HCP to correct the weight.

Nurse Intervention

If a patient is on alignment devices to correct the fracture, what should the nurse do to reduce infection

Rationale:

pin care everyday

Rationale:

pins are breaking skin integrity. Break in skin integrity can lead to infection at the points of entry

Nurse Education

what education should the nurse provide to the patient who has a cast

Rationale:

DO NOT

• get it wet

• remove padding

• insert objects

• put lotion in the cast

• bear weight

• cover it with plastic

Rationale:

adding water to the internal section of the cast / objects can increase the risk for infection due to breaks in skin integrity

DO

• keep it dry

  • cover it before showering

  • use a blow dryer to dry the cast after showering

• elevate above the heart for the first 48 hours

• move the extremities

• report odor, drainage, pain, swelling, discoloration of finger/toes, tingles

• educate the patient to do their cast and fracture appointment follow ups

Rationale:

Keeping the inside of the cast reduces the risk of infection

Risk Factors

what are the risk factors to have an amputation for

• middle / older adults = PVD, atherosclerosis, DM

• young adults = trauma (vets)

• osteomyelitis

• frostbite

Diagnostics

What are the diagnostics needed to determine if a patient might need an amputation

Rationale:

• X ray

• CT or MRI

• vascular studies

Rationale:

1. CT and X rays can help determine if osteomyelitis is present. The disease increase the risk for amputation

2. vascular studies show how far down the blood travels and help the doctor determine how much to cut

Nurse Interventions

A nurse is caring for a patient who will undergo surgery to amputate his left leg. What should the nurse educate / tell the patient prior to the start of the surgery

• get consent prior to start of the surgery

• explain the reason for the amputation

Nurse Intervention

A nurse is caring for a patient post-op from surgery. The patient underwent a left leg amputation. The nurse assess the incision site and notes lots of bright red blood saturating the gauze. What should the nurse do first.

Rationale:

Contact the HCP

Rationale:

the sutures may have opened up and caused hemorrhage. Circulation is being compromised . The patient needs to return to the operating room to fix the sutures. Life threatening

Nurse Intervention

What should the nurse assess after an amputation surgery

Rationale:

• do circulation checks

• do neuro checks

Rationale:

1. circulation checks establish good perfusion or lack there of

2. to monitor for neuro damage or compartment syndrome

Pathophysiology

Compartments syndrome is a decrease in pressure within a compartment that decompresses blood vessels, nerves, and/or tendons in the leg, arm, and shoulder.

 

True

False

Rationale:

False

Rationale:

Compartment syndrome is an increase in pressure directly related to tissue swelling.

Pathophysiology

What is phantom leg syndrome

Rationale:

Pain in a missing body part

Rationale:

the nerves are severed at the site of amputation. The brain is still sending signals to that area indicating pain

Treatment

A patient states “i got my amputation surgery 3 weeks ago, but I’m feeling pain where my leg use to be” What should the nurse do?

Give the pain medication

Risk Factor

what increases the risk to develop compartment syndrome

• trauma

• tight dressing or cast

• hemorrhage into compartment

Manifestations

What are the 6 Ps of compartment syndrome

1. pain

2. pallor

3. pressure

4. paresthesia

5. paralysis

6. pulseless

Rationale:

If a patient complains of any of these signs, then they are at risk for compartment syndrome. Notify the provider ASAP.

Diagnostic

what test is used before and after exercise to determine compartment syndrome risk

intercompartment pressure test

Treatment

A patient is at risk for compartment syndrome. What surgical treatment must be done

Rationale:

fasciotomy

Rationale:

this procedure relieves pressure caused by the syndrome. If not done, then the patient might need an amputation

Treatment

Name:

Mannitol

MOA:

Treatment

Name:

Mannitol

MOA:

used to decreased the high blood pressure when a pt has increased ICP

Pathophysiology

what are tonic-clonic seizures

the most common type of seizures. Involuntary miscle contractions and loss of consciousness.

Manifestations

what are the two most common symptoms of tonic clonic seizures

• muscle rigidity

• jerking movements

• lasts 1-2 mins

Nurse intervention 

• During the Seizure 

  • >5 mins →

  • Place them on seizure precautions 

    • Monitor LOC and keep airway 

    • If the seizure lasts more than 2 mins

• During the Seizure 

  • >5 mins → emergency → call 911 → keep track of duration and start time of seizure 

  • Assess if the patient has had a head strike → to determine further damage. 

  • Place them on seizure precautions 

    • Protect pt- don't restrain them and place them on their side → to prevent aspiration 

      • Have padded side rails 

    • Monitor LOC and keep airway 

      • Make sure suction and Ambu bag are at bedside

    • If the seizure last more than 2 mins

      • call 911 and note the start and duration of the seizure

Pathophysiology

what will a patients post ictal state be after a tonic clonic seizure

they will be hard to arouse and allow them to sleep

Nurse Interventions

what are common interventions a nurse can obtain when a pt is at risk of an active seizure

• document the start and duration of the seizure

• know which body parts are moving

Diagnostics

what are the diagnostics for generalized seizures

Rationale:

• EEG

• MRI

• SPECT

Rationale:

1. EEG show the seizure type

2. MRI show lesions on the brain

3. SPECT show which part of the brain is causing the seizure

Pathophysiology

what is a and absent / petite mal seizure

Manifestations

they space out and stare and don’t respond

Manifestations

• lasts seconds

• automatisms- sudden and repetitive motions (knee pats)

Pathophysiology

what is a and atonic seizure

Manifestations

Rationale:

when there is a lack of muscle tone and they completely pass out

Manifestations

• slump over

Rationale:

the sudden slump over increase the risk for head trauma

Risk Factor

what is the biggest risk factor for someone to develop seizures

Not compliant anti-seizure meds

Pathophysiology

what is a focal seizure and what are its subtypes

Complications

originate in one area of the brain

• simple partial- their conscious will stay intact

• complex partial- impaired conscious

Complication

the focal seizure can go from simple to complex

Pathophysiology

• what are febrile seizures. They have a rapid recovery of the post ictal state

tonic clonic seizures but with a high fever