Skills Quiz #3

What can a headache indicate?

can be sign of monro kellie doctrine, increased cranial pressure, or subarachnoid hemorrhage

Dysphagia

not an assessment but something to think about

any problems swallowing

use BURKE test where u drink fluid at once and choking = fail, but shows muscles that are affected

Focused Neuromuscular assessment Points

GCS/LOC- glasslow comma scale and lvl of consciousness

Follows commands

Vision- follow pen, cover eye and hold fingers

PERRLA- eyes equal and reactive and size of pupil, accommodation (look far away then close)

Eye movement

Extremities- up, down, grip, gas pedal, dorsi pedal

Speech- slurred?

Facial Symmetry- eyebrows, teeth/smile, nasal field

Sensation- is one side numb compared to other

Headache

Nuchal Rigidity (neck stiffness)- pushing down of hemorrhaging

Dysphagia 

What labs/diagnostics could you order?

blood glucose- if pt losses consciousness

ABG (arterial blood gas)- high CO2

CT Scan/MRI

Interventions for Neuro

if patient loses conciousness:

Low Sugar= hypoglycemic protocol

Overdose=Narcan/Flumazenil: narcan for narcotics and other for benzos

High CO2= Bipap: COPD, asthma;CO2 lvls build up

For decreased LOC

check when the last Narcotics or Sedatives were given.
May need Narcan or Flumanzenil (Reversal Agents)

What is pt doesn’t wake up?

gently stimulate the patient with touch. If still not waking up perform
sternal rub and/or pinch the finger and toe nails to produce pain stimuli.

This is also part of the Glascow Coma Scale. Stimulation is part of our assessments and not an intervention. We still need to treat the underlying cause

What if new or worsening s/s of stroke occur?

Code Stroke/Brain” may be initiated.
Student/New Grad nurses will notify their charge nurse and/or instructor.

This will call a neurologist to the bedside, a stat CT will be ordered, and Labs will be drawn.

Early recognition and treatment of stroke is crucial. We have 3-4.5 hours to administer TPA (Alteplase.

Glascow Coma Scale

used score unconcious pts 

scores eye opening, motor response, verbal response

Eye opening Scores

4- spontaneous eye opening

3- eyes open to speech

2- eyes open to pain

1- no eye opening

Motor Response Scores

6- obeys full commands

5- localizes to noxious stimuli

4- withdraws from noxious stimuli

3- abnormal flexion (decorticate posturing; flexes elbows/wrist while extending lower legs to pain; bundles to core)

2- abnormal extensor response (decerebrate posturing; extends upper/lower extremities to pain; celebrating)

1- no motor response

Verbal Resposne

5- alert and oriented

4- confused yet coherent speech

3- inappropriate words and jumbled phrases consisting of words (Ex. responding pizza to how are you)

2- incomprehensible sounds

1- no verbal response

FAST

quick neuro exam of face, arms, speech, and time used for strokes

F: Face

ask the person to smile

does one side of the face droop

A: Arms

ask the person to raise both arms

Does one arm drift downward

S: Speech

ask the person to repeat a simple phrase

Is their speech slurred or strange

T: Time

if you observe signs call 911

early prevention can help them get TPA

What if pts blood glucose is low?

give glucose

If CO2 elevated

bipap- helps people breath and release CO2

for COPD, asthma due to CO2 lvls build up

If suspected Overdose

give narcan for opioids

give Flumazenil for benzodiazepines 

What should you do for a seizure?

monitor/protect airway

turn in side if vomit

time it

give PRN ativan

Monroe Kellie Doctrine

brain is in a box

skulls volume is fixed w/ blood brain matter, CSF

if one of these increases in volume, brain can get squished and brain stem can die

Ex. tumor gets cut out, skull gets cut out and skin flap is left to allow brain to expand

Ex. brain bleeds, hole is drilled to drain blood and relieve pressure

Hydrocephalus- CSF has gone up, drill hole to drain or place shunt in chronic cases

Strokes

obstruction of blood flow to brain

hemorrhagic and ischemic

Hemorrhagic Strokes

Intracerebral, Subdural, Subarachnoid

Intracerebral Hemorrhagic Stroke

blood vessel in the brain ruptures

Subdural Hemorrhagic Stroke

collection of blood that forms between the brain and outer layer of brain (dura)

can happen when a person falls

remove bleeding

Subarachnoid Hemorrhagic Stroke

happens when blood leaks into subarachnoid space 

aneurysm is most common cause

people describe this as the worst headache of their life

How can you solve a Subarachnoid Hemorrhagic Stroke?

Surgery- cut skull, find aneurysm and clip it, blood clot forms and restores blood flow

Interventional Radiology (IR)- uses coiling, done in prevention, go in through femoral artery to brain and insert tools through tube and deploy a coil so blood clot forms, take pictures you move

Ischemic Strokes

occurs when there is a blood clot

can be due to atherosclerosis

high risk if increased cholesterol and smoking 

can use TPA  

What is TPA?

used for ischemic strokes

must be given within 3-4.5 hr if not area of brain will die

potent drug that increases risk of bleeding

thins blood

can’t have surgery within 30 days

given through IV

if more than 4.5 hours, go to IR

What would be the process if someone is having a stroke?

CT scan is priority

can show us if its hemorrhagic

If its neg for hemorrhagic, give TPA

What is the NIH stroke scale used for?

used for ischemic strokes

Lungs

loading docks, pick up O2 from air and drop CO2

Hemoglobin

storage containers filled w/O2 away from lungs and CO2 back to lungs

RBCs

carry hemoglobin which carries O2 and CO2

Heart

pushes train

Blood Vessels

train tracks fro RBCs

Organs

train stops and drops of O2 and pick up CO2

Murrmur

when valves dont close well 

Cardiac output

the volume of blood the heart pumps out each minute

comes out of aorta

What can chest pain indictae?

block in heart which messes w/O2

Perfussion

delivery of O2 to tissues and organs

Edema

fluid can get backed up and goes to tissues

mostly in legs because it most distal from the heart

What should be the normal sound of heart

lub dub whoosh (when O2 gets pushed out)

Ventilation

gas exchange

O2 in and CO2 out

What factors affect oxygenation?

Bad Heart- slows O2 delivery (train cars)

Arrhythmias- abnormal rhythm (slow train cars)

Low Bp- slows down O2 delivery

Anemia- low RBCs; reduces ability to deliver O2 to organs/tissues

Physical Changes- lungs can’t expand (Hunchback using L lung to breath)

Age- Infants (smaller lungs= faster) and Older (less elasticity in lungs and blood vessels)

Medications- narcotics can lead to low RR

Cigarette Smoking- bad lungs, bad exchange; plaque in vessels leads to poor circulation

Environmental conditions: smoke, pollution

Psychological- stress

Rales/Crackles

sound like crackling

Fine: crispy, starts at base of lungs and is high pitched

Coarse: louder, longer, sounds like bubbling only in lungs

Wheezing

sounds like whistling 

happens during allergic reactions

Rhonci

rumbling

snoring, pneumoni, Cystic fibrosis,

in bronchioles, rumbling and louder

clears after coughing

Stridor

upper airway high pitched whistling

emergency

louder over throat

loud wheeze

must be heard in throat (opera singer)

airway is closing

Pleural/Frictional Rub

related to pleurisy

What should you asses in a Resp Focused Exam?

RR- normal is 12-20

Reg. Symmetrical- left to right, is one lung bigger?

Breath sounds

O2 sats and O2 amount- keep greater than 94% except for COPD

Cough- Productive (bringing mucus), dry or wet, when it started

Sputum- amount, color, size

SOB

Labored vs Unlabored (severe SOB, uses all muscles)

O2 amount for COPD patients

give 88% because if more than 94%, brain will tell them to stop breathing due to CO2 retention

Narcotics and RR

can decrease RR

RR of 10 can be normal

RR of 6-8 is an emergency and give narcan

Labs and Diagnostics for Focused Resp

ABG- arterial blood gas

ETCO2- attaches to cannula and detects CO2, normal= 36-45

Sputum culture

CXR- chest x ray for SOB

CT Scan- detailed view after CXR

VQ Scan- for pulmonary embolism to see blood clots tests perfusion in lungs

Interventions

Wheezing- bronchodialaters (albuterol)

Rales= suctioning or Lasix (to get rid of fluid du to heart failure/infection)

Low sats= Increase O2

Low RR= OD give narcan

What is the treatment for stridor

Racemic Epinephrine Nebulizer

bronchodilator

may have to be intubated if this doesn’t work

What heart conditions can affect perfusion?

arrhythmias that affect SA and AV node

hypertrophy- muscle becomes weak/loose

Ischemic tissue (dead muscle)

decreased heart rate

atherosclerotic- build up in arteries

arterial stiffness

if heart goes too fast it can’t fill up

leaking valves that cause murmur

Bradycardia

less than 60 bpm

tachycardia

greater than 100 bpm

S1

closing of valves at the start of systole

first sound 

lub sound

S2

closing of aortic and pulmonary valves at the end of systole

dub sound

2nd sound

Cardiac Focused Assessment

Chest Pain- PQRST - Question if radiating. Heart attack typically has radiating chest pain and radiating to left arm

Heart Sounds – S1 S2, S3, S4, Murmurs, Clicking=Mechanical Valves

Jugular Venous Distention (JVD)- sign of R heart failure

Edema +1-4

Telemetry/ ECG -Need to know normal vs abnormal. Seek expert assistance if abnormal.

Cap Refill x4

pulses x4

heart rhythm and sounds

Previous Vital signs. Monitor the trends.

History

Medications

Doppler U/S if needed.

Labs and Diagnostics

Labs – Specifically BNP= CHF, Cardiac Enzymes, CBC (Train Cars), CKMB, Pt, Ptt, INR, Trop, D-Dimer

Ultrasound, EKG, Echo, Stress assessment, Angiogram

Interventions

Chest Pain= MONA

Shock=Fluids, Treat = ?Sepsis? Hypovolemic? cardiogenic

Interventions for MI

cardiac enzymes, EKG, MONA

Cardiac enzymes

Trop, CK, CKMB

when detected in blood, sign of cardiac damage (heart attack)

D-Dimer

sign of blood clots

DNT will have elevated D-Dimer

Clotting Times

Pt, Ptt, INR

when elevated blood is thin

risk of bleeding

CBC

complete blood count

WBC count: elevated=infection

RBC count: low=anemia or bleeding

Hemoglobin Hemacroit: low sign= sign of bleeding

Platelets:low risk of bleeding

CMP

metabolic panel

Glucose: decreased=diabetes

BUN: creatinine= sign of heart failure

Na, K, Ca: electrolytes; of decreased of imbalanced can affect electrical currents lead to arrhythmias or irregular telemetry 

EKG

for irregular heart rate

can determine if they will or have had MI

Echocardiogram/Ultrasound of heart

can detect murmur of failure

Heart Stress Test

check telemetry (EKG) while you exert heart  and look for abnormalities

sprinting on treadmill

Angiogram

inject dye and check blood flow in coronary arteries

coronary artery stenosis- blood clot can form and cause MI

place stent to keep open

MONA

Morphine- reliefs pains

Oxygen- improves oxygen supply to muscle

Nitroglycerine- salvage heart muscle by dilating blood vessels

Aspirin- platelet aggregate, platelets become less sticky to prevent clot from getting bigger

JVD

juglar vein distension

caused by fluid build up when R. side of heart isn’t working

will get edema and JVD due to pressure

0+ Edema

no pitting edema

1+ Edema

2mm mild pitting

Edema that disappears rapidly

2+ Edema

moderate pitting edema

4mm depression that disappears in 10-15 secs

3+ Edema

moderately severe pitting edema

6mm depression that may last more than 1 min

4+ Edema

severe pitting edema

8mm depression that can last more than 2 mins

Poor Circulation Problems

cyanosis- blue in fingers

pallor- pale appearnce

DVT

deep vein thrombosis

swelling and calf pain

if suspected remove SCDs ir Ted stockings and place patient on bed rest

consult MD and suggest ultrasound of leg