NCLEX Prep

acute pain

protective, temporary, self-limiting and resolved with tissue healing

chronic pain

ongoing or recurs frequently lasting longer than 3 months, and persisting beyond tissue healings

nociceptive pain

damage or inflammation of tissue other than that of the peripheral and central nervous systems

neuropathic pain

abnormal or damaged pain nerves

somatic pain

pain in the bones, joints, muscles, skin or connective

visceral pain

pain in internal organs such as the stomach or intestines “referred pain”

hydromorphone, fentanyl, morphine, oxycodone, methadone,

common opioids

adverse effects of opioids

constipation, orthostatic hypotension, urinary retention, nausea/vomit, sedation, and respiratory depression

meningitis

inflammation of the meninges which are the membranes that protect the brain and spinal cord

what microbes can cause meningitis

• bacteria

• viral

• fungal

vaccines for meningitis

• Hib vaccine

• pneumococcal polysaccharide

• meningococcal

viral meningitis risk factors

mumps, measles, herpes, west nile virus

bacterial meningitis risk factors

pneumonia, otitis media, flue

other causes of meningitis

immunosuppression, contamination of spinal fluid, or skull fracture

physical findings of meningitis

• headache

• nuchal rigidity (stick neck)

• photophobia

• ALOC

• kerning sign

• brudzinski sign

• red macular rash

what is a positive kernig sign

resistance and pain with extension of the leg from a flexed position

what is positive brudzinski sign

flexion of the knee and hips occurring with deliberate flexiion of the client’s neck

diagnostic procedures for meningitis

lumbar puncture

what does cloudy spinal fluid meaning

bacterial meningitis infection

what does clear spinal fluid meaning

viral meningitis infection

what precautions are needed for meningitis patients

droplet precautions

nursing care for meningitis patients

• HOB 30 degrees

• decrease environment stimuli

• avoid coughing and sneezing

• seizure precautions

what are the three complications of meningitis

• increased ICP

• SIADH

• Septic emboli

seizure

abnormal, excessive and uncontrolled electrical discharge of neurons within the brain

risk factors for seizures

• genetics

• fevers

• cessation of antiepileptic drugs

• hyponatremia

• hypoglycemia

• stroke

• head trauma

tonic-clonic seizure

stiffening of muscles, loss of consciousness, and rhythmic jerking of extremities

tonic seizure

lose consciousness, increase muscle tone, apnea, vomit, incontinence, arrhythmia

clonic seizure

rhythmic jerking of extremities, lasts several minutes, muscles contract and relax

myoclonic seizure

brief stiffening of the extremities which may be symmetrical or asymmetrical

atonic seizure

loss of muscle tone (falls!), followed by periods of confusion

absent seizures

loss of consciousness for 10-30 seconds, no motor activity (no blinking), occur several hundred times a day

complex partial seizures

behaviors the client is unaware of (lip smacking, picking at clothes), loss of consciousness, amnesia occurs immediate before and after seizure

simple partial seizure

consciousness maintained, deja vu, change in heart rate, abnormal flushing, or offensive smell