N162B: Exam 2 (copy)

A patient sustains an electrical burn from a power socket. What does the nurse need to be aware of?

the iceberg effect

What is concerning about the iceberg effect?

The damaging effects inside the body can be more severe than the outside

When working on the house's electrical system, a patient sustains an electrical burn. What should the nurse assess the bones for?

fracture due to the voltage of the shock

What is a cardiac concern associated with electrical burns and what should the nurse do?

• cardiac dysrhythmias

• order a STAT EKG

What is a renal concern associated with electrical burns?

AKI due to massive muscle breakdown and the release of myoglobin which can clog the glomerulus and cause the AKI

In a chemical burn which is worse: alkaline or acid burn?

Alkaline because alkali burns continue to burn even after the agent is neutralized

Why are alkali burns difficult to manage?

they cause protein hydrolysis and liquefaction

A patient arrives to the ED with liver disease presenting like cirrhosis. Symptoms include pitting edema of the lower extremities. Why is this?

The liver is unable to make albumin. Albumin is:

• the largest amount of protein in blood

• responsible for keeping colloidal pressure within vasculature

What happens as a result of albumin levels decreasing in liver disease?

Fluid escapes out of the vasculature into the interstitial space causing edema

You are assigned a patient with cirrhosis. What education points must you make?

avoid things that can cause further damage such as alcohol ingestion

What is lactulose?

laxative

What condition can lactulose aid in that is associated with advanced cirrhosis?

hepatic encephalopathy

How does lactulose work in hepatic encephalopathy and advanced cirrhosis?

it will cause a decrease in ammonia levels due to it being excreted via the feces and the patient’s LOC will improve

What is a paracentesis?

a procedure performed on patients with ascites to tap fluids out of the peritoneal cavity

How does paracentesis help?

Patients can breathe easier since the liquid abdominal pressure that puts pressure against the diaphragm is gone

What is an important nursing consideration for paracentesis?

the patient must empty their bladder prior to initiating the procedure

What can cause ascites?

a patient may have liver disease and suffer from hepatic portal hypertension

What is neomycin and when is it used?

antibiotic used in patients with high ammonia and hepatic encephalopathy

How does neomycin work?

It affects ammonia producing bacteria in the gut, decreases the amount of ammonia produced and thus improves hepatic encephalopathy improving patient LOC

What are NANDAs for cirrhosis?

• imbalanced nutrition: less than body requirements

• fluid volume excess

• ineffective breathing pattern

• risk for injury

• risk for acute confusion

• disturbed body image

• deficient knowledge

What is steatorrhea?

fatty, frothy, smelly stool due to increased amount of fat in the stool

• associated with acute pancreatitis

• pain worsens when lying supine

• smell of food can stimulate pancreatic secretion

• pain with alcohol consumption

How is Hepatitis A transmitted?

fecal oral route

What is proper education to give individuals who wish to prevent hepatitis A?

proper hand hygiene

What are some causes of ICP?

What is an initial sign of increased ICP?

decreased LOC

You have a patient presenting with increased ICP. What would you educate your patient NOT to do?

• valsava maneuver (make sure they do not get constipated)

• buildup airway secretions (no coughing)

• hip flexion

• abdominal distention

• lie supine (decreases cerebral drainage)

What are some presentations of ischemic stroke?

• sudden onset of facial weakness

• unilateral weakness (opposite side)

• confusion

• expressive aphasia

• receptive aphasia

• headache

• nausea

• visual disturbance

• vertigo

• numbness and tingling

What are some common presentations of hemorrhagic stroke?

• gradual onset of symptoms

• N/V

• HTN

• Confusion to altered LOC

• headache

• respiratory issues

What is a TIA?

stroke episode that lasts less than 24 hours but most last less than 1 hour

• predictor of stroke

What are common presentations of basilar skull fractures?

• raccoon eyes

• battle sign

• hemotympanum

• halo sign

  • CSF otorrhea

  • CSF rhinorrhea

• no neuro sx

What is the pathophysiology of multiple sclerosis?

• CNS demyelination leaves sclerotic areas or plaques along with scarring

• causes neuro weakness, spasticity, visual disturbances, and paresthesia

• most prevalent further from equator due to low vitamin D

What test differentiates between a myasthenic crisis and a cholinergic crisis?

Tensilon test

• uses edrophonium

• myasthenic pt will improve

• cholinergic pt will worsen

  • give atropine antidote

What is ALS?

Amyotrophic Lateral Sclerosis

• rare progressive neuromuscular disease marked by loss of motor neurons

• ASYMMETRIC

• involves upper and lower motor neurons in spinal cord, brainstem, and cerebral cortex

What remains intact for ALS?

cognition

What is dementia?

loss of capacity to remember, think, or make judgments that interfere with daily tasks

• manifestations occur gradually

• Alzheimers

• not normal aspect of aging

What is delirium?

state of confusion that develops over hours to days

• decreased ability to focus, sustain, direct, and shift attention and awareness

• caused by beeping, constant lights, noise, lack of human touch

What is the most common form of dementia?

Alzheimers

What are common triggers for delirium?

• dehydration

• dementia

• electrolyte imbalance

• emotional stress

• disorder of lung or liver

• infection

• ICU

• drugs

• immobility

• untreated pain

What are common interventions for delirium patients?

• assess pt self-care needs

• provide for all pt needs

• provide reassurance

• reorient pt to person, place, time, and event

• use distraction for agitation

• manage fever, pain, nausea, and sx

• implement measures to sleep

What is an epidural hematoma?

bleeding into the space between the skull and dura mater

• 90% of adults have skull fractures

• most commonly temporal bone which lacerates the middle meningeal artery

In an epidural hematoma, what can occur if the superior sagittal sinus tears?

venous epidural bleeding

What chain of events occurs with epidural hematomas?

• immediate post-traumatic period of unconsciousness

• lucid interval

• rapid deterioration in LOC

  • sleepiness

  • confusion

  • obtundation

  • coma

  • death

What are characteristics of primary brain injury?

• initial mechanical insult is to brain

• primary injury is localized to the head

What are causes of a primary brain injury?

• laceration

• skull fracture

• cerebral contusion

• concussion

• hematoma

• diffuse axonal injury

• damage to blood vessels

• foreign object penetration

What are characteristics of a secondary brain injury?

• the brain’s response to the initial injury

• progressive insult that evolves following the primary injury

What is a chain reaction associated with secondary brain injuries?

• inadequate CPP (cerebral perfusion pressure)

• cerebral ischemia

• ischemia cascade

• cerebral infarction

What can secondary brain injuries result from?

• hypotension

• hypoxia

• anemia

• fever

What is a depressed skull fracture?

• displacement of a comminuted skull fracture

• frequently seen with other brain injuries

  • cerebral contusions

  • lacerations

What can cause a depressed skull fracture to become infected?

hair, dirt, and debris found in the wound

What is a TIA?

• episode of stroke sx that lasts briefly

• less than 24 hours but usually last less than 1 hour

What does a TIA tell you?

the patient is at high risk for a stroke

• risk after TIA is 10-15% in 1st 3 months

• urgent evaluation needs to be done since stroke and TIA share same etiology

What is the acronym assessment for a stroke?

• Balance (sudden loss of balance?)

• Eyes (lost vision in one or both eyes?)

• Face (face look uneven?)

• Arms (one arm hanging down?)

• Speech (speech slurred? trouble speaking or confused?)

• Time (call 911 now!)

What are the initial actions for a stroke?

• ABC’s

• provide O2 via NC

• VS

• cardiac monitor (anticipate EKG)

• baseline neuro assessment

  • GCS, pupil check, mNIHSS

What is the most important information to receive from the patient or family of a suspected stroke patient?

initial time of symptom onset and time last known well

What is a hemorrhagic stroke?

• sudden bleeding in the brain without trauma

• headache often present

• other sx depend on location of bleed

What causes hemorrhagic stroke?

• HTN

• amyloid angiopathy from age, metastatic disease, vascular malformations

What is the most common cause of subarachnoid hemorrhages?

aneurysms

What does the nurse need to monitor for TPA?

• VS

• neuro check

• mNIHSS

• q15m × 2hours

• q30m × 6hours

• q1hr x 16hours

What does the nurse need to observe when the patient is on TPA?

• sudden headache

• oozing from orifice

• pain anywhere in the body (retroperitoneal)

• sudden unconsciousness