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What are the three parts of the skull?

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What are the three parts of the skull?

  • Brain tissue 80%

  • Blood 10%

  • Cerebrospinal fluid 10%

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What is a normal ICP?

  • 0-15 mm HG (>20 no good)

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What influences ICP?

  • Arterial/venous pressures

  • Intraabdominal and intrathoracic pressure

  • Posture

  • Temperature

  • Blood Gases (CO2)

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What is monroe-kellie doctrine?

  • If volume of one of the components increases, the other ones prob will too

    • Change in CSF

    • Change in intracranial blood volume

    • Change in brain tissue volume

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What are clinical manifestations of increased ICP?

  • Changes in Level of Consciousness

  • Ocular signs

  • Altered motor function

  • Headache

  • Vomiting

  • Vital Signs (Cushing’s Triad)

  • Complications → Inadequate cerebral perfusion and herniation

  • Widening pulse pressuer

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What is cushing’s triad? Where do you see it?

  • Increased BP

  • Decreased HR

  • Decreased Respirations

  • Increased ICP

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What happens if MAP is too high?

  • CBF increases and maximal vasoconstriction of blood vessels

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What happens if MAP is too low?

  • CBF decreases and cerebral ischemia can occur

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What is normal CPP? What happens if it decreases?


  • Normal CPP is 60-100 mm HG

  • When decreased, autoregulation fails and CBF decreases

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What is decorticate and decerebrate rigidity?

  • Decorticate have arms flexed towards the core

  • Decerebrate has extensions and usually more serious

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How to diagnose ICP?

  • Respiratory and neurological assessments

  • ABGs

  • Cushing’s triad

  • MRI and CT

  • EEG

  • Cerebral angiography

  • ICP measurement

    • Ventriculostomy / Fiberoptic catheters

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Would you perform a lumbar puncture on a patient with increased ICP?

  • No because it can cause herniation

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What is proper positioning for lumbar puncture?

  • On the side

  • Sitting, leaning over

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What to make sure with lumbar punctures?

  • Make sure there are pulses distal to the area

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How would you care for increased ICP? Surgery?

  • Provide quiet, calm environment → Decrease stimuli

  • Nutrition Therapy → Should be initiated ASAP after a cerebral injury (increase protein or calories)

  • Surgery:

    • Craniotomy: Remove part of skull

    • Ventriculostomy: Remove CSF fluid

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What is drug therapy for ICP?

  • Corticosteroids

  • Osmotic diuretics (mannitol IV)

  • Intravenous Hypertonic Saline

  • Acetaminophen

  • Sedatives

  • Ativan (Lorazepam)

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What are nursing interventions for increased ICP?

  • Maintain oxygen and respiratory (ventilation if needed)

  • Monitor cardiac function (telemetry)

  • Fluid and electrolyte balances

    • IVFs and electrolyte balances

    • I/Os and daily weights

  • Monitor ICP

    • Avoid activities that can increase ICP

    • Avoid long suction and flexions

  • Positioning (30-40)

  • Skin care; Q2 hour turning

  • Prevent injury

  • Psychological and psychosocial care

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Who is more likely to have brain tumors?

  • Middle aged males are more likely

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What is a primary brain tumor? How are they classified?

  • Forms within brain tissue

  • Classified by tissue where developed

    • Meningomas most common (benign)

    • Gliomas are mostly malignant

    • Oligodendrogliomas

    • Acoustic neuromas

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What are secondary brain tumors?

  • Most common; metastasis from another cancer

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What are clinical manifestations of brain tumors?

  • Headache

  • Nausea and vomiting

  • Seizures

  • Mood/Personality changes

  • Aphasia

  • Motor weakness opposite side

  • Muscle weakness

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What kind of medications with tumors?

  • Steroids for edema

  • Check blood glucose

  • H2RA’s and PPIs for ulcers

  • Kepra for seizure

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What kind of changes will you see with a frontal lobe tumor?

  • Changes in:

    • Personality

    • Judgement

    • Intellect

    • Memory

    • Broca’s aphasia (understand)

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What kind of changes will you see with a parietal lobe tumor?

  • Changes in:

    • Speech

    • Writing

    • Sensory

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What kind of changes will you see with a Occipital lobe tumor?

  • Changes in:

    • Vision

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What kind of changes will you see with a temporal lobe tumor?

Changes in:

  • dysphagia

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What are treatments for brain tumors?

  • Surgery

  • Radiation

  • Ventricular Shunting

  • Chemotherapy

    • IV, PO, Intrathecal

  • Targeted therapy

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What is meningitis? What is the patho? Cause?

  • Inflammation of the brain tissue

  • Caused by Bacteria, virus, or aseptic

  • Bacteria/Virus enter cns via blood or respiratory → Inflammation occurs due to infection → Increases CSF production and ICP

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Who is most at risk for meningitis?

  • Older adults

  • Debilitated

  • Institutionalized people (prisons)

  • College students

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What are clinical manifestations of meningitis?

  • Fever, severe headache, nuchal rigidity, photophobia

  • Decreased level of consciousness → coma (poor prognosis)

  • Signs and symptoms of increased ICP

  • Skin rash and petechiae (meningococcal)

  • Hyperextension of head and back arch (opisthotonus)

  • Kernig and Brudzinski

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What are complications of meningitis?

  • Increased ICP: most common

    • Headaches (for months)

  • Residual neurological dysfunction

    • Hemiparesis, Dysphasia, Hemianopsia (blindness in half of visual field)

  • Cranial Nerve dysfunction

  • Cerebral edema → seizures → coma → death

  • Waterhouse-Friderichsen syndrome

  • Shock

  • Disseminated intravascular coagulation (DIC)

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How to diagnose meningitis?

  • Neuro assessment first

  • CT scan of head/brain

  • Blood cultures

  • Lumbar puncture → CSF shows neutrophils, protein

    • Presence of CSF pleocytosis (increased cells)

  • CBC

  • Culture sputum/throat/nose

  • Xpert EV test - rapid test; sample of CSF tested for enterovirus

  • Polymerase chain reaction (PCR)

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How to care for meningitis?

  • Rest

  • IV fluids (monitor fluids, I/Os)

  • Calm environment/Decrease stimuli

  • Drug therapy

    • Codeine

    • Acetaminophen or aspirin

    • Dexamethasone (decadron) (steroid for inflammation)

    • Mannitol (Osmitrol)

    • IV antibiotics → Penetrate BBB

      • Penicillins

      • Cephalosporins

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What are nursing interventions for meningitis? (not direct care)

  • Health promotion

    • Vigorous treatment of respiratory illness

    • Vaccinations

  • Pain relief and fever treatment

  • Proper positioning

  • Photophobia treatment

  • Seizure precaution

  • Fluid replacement

  • Droplet precautions

  • Nutrition

  • Psychosocial care

  • Treat residual side effects

  • Rest but slowly reinitiate activities

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What is viral encephalitis?

  • Acute inflammation of the brain caused by a virus

    • Ticks, mosquitoes, west nile virus

    • Potential complications from chickenpox, measles, or mumps

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What are clinical manifestations of viral encephalitis?

  • Fever, headache, nausea, vomiting

  • Alteration in mental status (mild to coma)

  • Symptoms of increased ICP

  • Focal neurological deficits

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How to diagnose viral encephalitis?

  • MRI, CT scan of brain and PET scan

  • Lumbar puncture

  • PCR testing for HSV and West nile Virus

  • Blood test for west nile virus → Detects viral RNA

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What are meds and things we can do to manage encephalitis?

  • Focus on prevention and treat symptoms

  • Mosquito control

  • Diuretics (decrease cerebral edema)

  • Corticosteroids

  • Antiviral medications (acyclovir)

  • Anti-seizure medications

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What are primary headaches?

  • Headaches that are either tension type, migraine, or cluster headaches

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What is a tension headache?

  • Bilateral frontal-occipital headache

  • Constant, heavy pain to face, head, & neck; photophobia may be present

  • Muscle tightness in neck

  • Band like pain/pressure

  • most common

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What is a cluster headache?

  • Neurovascular

  • Severe, extreme pain (unilateral)

    • In and around the eye (most severe)

    • Sharp, stabbing pain

  • Agitation/Restlessness

  • Photo/phonophobia

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What are migraine headaches?

  • Vascular

  • Pulse like or throbbing headache

  • Unilateral

  • Auras can be present

  • Want to “hibernate”

    • Photophobia and phonophobia

    • Dizziness, nausea/vomting, etc

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What are risk factors for migraines?

  • Family history, foods triggers, stress, hormones, medications, fatigue, tension headaches

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How to care for headaches?

  • Increase comfort and decrease anxiety

  • Patient teaching → avoid stressors

  • Development of positive coping strategies

  • Increased quality of life and decreased disability

  • Headache diary

  • Relaxation, cognitive behavioral therapy

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What to do during a headache?

  • Calming environment; dim lighting

  • Massage neck; moist heat

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What are drug therapies for headaches?

  • Non-opioid analgesics (Aspirin, Tylenol, NSAIDS)

  • Combination analgesics

  • Muscle relaxants

  • Tricyclic antidepressants, SSRIS, or mirtazapine

  • Antiseizure medications - topiramate (topamax) or gabapentin (neurontin)

  • Triptans (sumatriptan)

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How to treat cluster headaches?

  • !00% oxygen at 6-8L/min

  • Triptans (sumatriptan)

  • Verapamil (Calcium channel blockers/antihtn), lithium, antiseizures

    • Possibly for prevention

  • Nerve block deep brain stimulation, or neurosurgical ablative procedures

  • Botulinum toxin A (botox) injections

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What is trigeminal neuralgia? What nerve does it affect

  • AKA tic douloreux

  • Involves the trigeminal nerve 5

  • Compression of the superior cerebellar artery

    • Causes irritation and compression of the trigeminal nerve

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What are risk factors for trigeminal neuralgia?

  • Herpes viral infection, tooth/jaw infections, trauma, or cerebral masses

  • Women, multiple sclerosis

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What are clinical manifestations of trigeminal neuralgia?

  • Lots of pain

  • Twitching, grimacing

  • Blinking an tearing

  • Sometimes senosory loss

  • Occur as brief attacks (unilateral)

    • 2-3 mins, once/multiple per day

  • Precipitated by stimuli/triggers

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How to diagnose trigeminal neuralgia?

  • H&P neurological assessment

  • Magnetic resonance image (MRI)

  • Computed tomography (CT)

  • Electromyography (EMG)

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How to care for the patients with Trigeminal neuralgia?

  • Nerve block, electrical stimulation of nerves, botox injection

  • Surgery:

    • Percutaneous: Glycerol rhizotomy or radiofrequency rhizotomy

    • Microvascular decompression: craniotomy to decompress affected blood vessels

    • Stereotactic radiosurgery (gamma knife): precise radiation to trigeminal nerve

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What drugs are used for Trigeminal Neuralgia?

  • Focus on nerve firing

  • Antiepileptic medications (carbamazepine)

  • Tricyclic antidepressants

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What to do as a nurse for trigeminal neuralgia?

  • Monitor patients reflexes and sensations

    • Protect eyes if corneal reflex is impaired

  • Hygiene, oral care, nutrition

    • Warm water

    • Soft towels

    • Electric razors

  • Decreasing environmental stressors

  • Post op procedures

  • Emotional support

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What is Seizure/Epilepsy?

  • Epilepsy: Spontaneous recurring seizures

    • Uncontrolled electrical discharge of neurons

    • Can cause loss of oxygen and perfusion

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What risk factors and causes seizures/epilepsy?

  • Risk: Alzheimer’s or stroke family history

  • Idiopathic/cryptogenic

  • Due to systemic/metabolic disturbances

  • Metabolic: acidosis, electrolyte imbalances, hypoglycemia, hypoxia, alcohol/drug withdrawal, dehydration, water intoxication

  • Systemic: Lupus, diabetes

  • Extracranial: heart, liver, lung diseases, hypertension, septicemia

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What are the three seizure phases?

  • Preictal phase

    • Aura experienced

  • Ictal phase

  • Postictal phase

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What are tonic clonic seizures (gran mal)?

  • Tonic (stiffness)

  • Clonic (Jerking)

  • Don’t remember

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What are absence seizures?

  • Inattentive

  • Blank stare

  • don’t remember

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What are myoclonic seizures?

  • Brief Contraction of muscles

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What are atonic seizures?

  • Brief loss of muscle like toys

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What are focal seizures (focal)?

  • One part of brain is affected

  • Like speech (aphasia)

  • Automatisms: like chewing

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How to diagnose seizures/epilepsy?

  • H & P

  • Seizure history

  • electroencephalogram (eeg)

  • CT/MRI of brain → rule out lesions

  • Metabolic labs

    • CBC, Liver Function tests, urinalysis

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How to care for seizures?

  • Goal: treat underlying cause, prevent seizures

  • Seizure precautions

  • Surgical: Remove epileptic focal area

  • Vagal nerve stimulator

  • Keto diet (decreases glucose)

  • Patient training

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What are drugs for seizure/epilepsy?

  • Rapid (short acting)

    • Ativan

  • Long acting

  • Single/Combination therapy

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What is amyotrophic lateral sclerosis? (ALS)

  • AKA lou gehrig’s disease

  • Rare disease that degenerates motor neurons in brainstem and spinal cord

    • Brain intact

  • Quick progression → death in 2-10 years

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How to diagnose ALS?

  • No diagnose

  • History of present illness

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Who is more at risk of ALS?

  • Men usually > 50s

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What are the manifestations of ALS?

  • Weakness in extremities

  • Dysarthria, dysphagia, drooling

  • Muscle wasting (spasticity/cramping)

  • Pain

  • Sleep disorders, emotionally labile; depression

  • No cognitive impairments

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How to care for ALS patients?

  • Exercise → Endurance based to decrease spasticity

  • Support cognitive and emotional functioning

  • Nutrition

  • Reduce risk of aspiration and decrease risk of injury

  • Treat pain

  • Support family/friends

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What are drug therapies for ALS?

  • Riluzole (rilutek)

    • Decreases glutamate in the brain

    • Delays need for tracheostomy

    • Delays death

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What is Guillain-Barre syndrome? What does it affect?

  • Acute, rapidly progressing polyneuritis/polyneuropathy

    • Ascending bilateral paralysis affecting peripheral nervous system and cranial nerves (stars in lower extremities)

  • Rare; can be fatal

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What is the cause and patho of Guillain-Barre syndrome?

  • Occurs due to cell mediated or humoral immunological response

    • Trauma, viral, vaccine, or bacterial infection

      • Most common → campylobacter jejuni/cmv

  • Loss of myelin, edema, and inflammation of affected nerves

  • Decreased or absent nerve impulses leading to paralysis, loss of reflexes, and muscle tone

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What are clinical manifestations of Guillain-Barre Syndrome?

  1. Pain, paresthesia, and hypotonia (v muscle)

  2. Areflexia (no tendon reflexes), weakness/paralysis of lower extremities

  3. Progressive paralysis occurs rapidly

    1. thoracic area and cranial nerves

    2. Facial paralysis

  4. Autonomic nervous system dysfunction

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How to diagnose guillain-barre syndrome?

  • Based on clinical manifestations and patient history

  • CSF analysis

  • EMG

  • MRI of brain

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How to treat Guillain-Barre syndrome?

  • Ventilation and respiratory support (trachs)

  • Monitor respiratory function, cardiac status, reflexes, and muscle tone

  • Monitor vitals

  • Skin care; turning and repositing, exercises

  • Emotional support

  • Plasmapharesis

  • Immunoglobulins (IVIG, sandoglobulin)

  • Tube feeds or TPN

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What is carpal tunnel syndrome? Cause?

  • Compression of the median nerve

  • Caused by pressure related trauma or edema

    • Occupation and hobbies requiring repetitive movements of the wrist

    • Hormones

    • Other disorders

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What are the clinical manifestations of carpal tunnel syndrome?

  • Weakness, pain, numbness, and impaired sensations

    • Along distribution of median nerve

  • Difficult performing fine hand movements

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How to diagnose carpal tunnel syndrome?

  • Tinel test

  • Phalen test

  • Radiographic studies

    • Atrophy of thumb muscles; dysfunction of hand (in late stages)

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How to care for carpal tunnel syndrome?

  • Adaptive devices

    • Braces or splints

    • Special keyboard pads or mouse for computer

  • Ergonomic changes

    • Proper body mechanics

    • Avoid extreme temperatires

    • Frequent breaks

    • Exercises/PT if needed

  • Corticosteroid injections

  • Surgery

    • Open release surgery/endoscopic

    • Rehab post op

    • Monitor pain and neurovascular status post op

    • Check below pulses and cap refill

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What is gout?

  • Accumulation of uric acid crystals

    • Incidence → predominantly in middle aged men; higher incidence in african american

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What is primary and secondary gout?

  • Primary: hereditary

  • Secondary: Caused by other diseases and medications (or others)

    • Diuretics (thiazide diuretic), renal disease, crash dieting/fasting, immunosuppressive drugs after organ transplantation

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What are risk factors for gout?

  • Obesity

  • Use of thiazide diuretics

  • Hypertension

  • Excessive alcohol intake

  • High purine diet

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What are clinical manifestations of Gout? Phases?

  • Acute, intercritical, and chronic

  • Acute:

    • Pain and inflammation at affected joints

    • Joint tenderness, swelling, and warmth (sometimes redness)

  • Chronic gout (Tophaceous)

    • Repeated gout attacks and presence of Tophi

    • Arthritis like symptoms

    • Complications → Urinary or kidney stones; pyelonephritis; renal obstruction; and joint destruction

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What are drugs used for acute gout and to prevent it?

  • Colchicine, NSAIDS, glucocorticoids

  • To prevent further attacks → Allopurinol or probenecid (sometimes with colchicine and NSADIs)

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What are drugs used for chronic gout due to hyperuricemia?

  • Febuxostat (uloric)

  • Allopurinol (zyloprim)

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How to treat gout?

  • Rest and immobilization during gouty attacks

  • Elimination of alcohol and high purine foods

  • Weight loss

  • Encourage proper fluid intake

  • Avoid aspirin

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What is a sprain?

  • Injury to ligament surrounding a joint

  • Most common in ankles, wrist, and knees (ex. acl)

  • Can be very painful

  • Pain, edema, ecchymosis, decreased function/weight bearing

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What is a strain?

  • Excessive stretching of a muscle or tendon

  • Most common in lower back, calves, and hamstrings

  • Pain, edema, spasms, ecchymosis, internal bleeding (3rd degree strain)

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What is management for sprains/strains?

  • RICE x 24 → 48 hrs for 1st and 2nd

  • R: Rest

  • I: ICE

  • C: Compression

  • E: Elevation

  • After 48hrs, apply warm moist heat

  • Encourage use of limb but support it

    • Aim to strengthen the affected area

    • Use of brace if warranted

  • Health promotion and prevention

    • Proper stretching, warm up before exercise

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What is causes amputations?

  • Harzardous occupation, circulation impairment, thermal injury, trauma, or tumor

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When are amputations indicated when?

  • Extremity has:

    • Loss sensation

    • Inadequate circulation

    • Pallor/Necrosis

    • Local infection

    • Vascular studies indicate the patient is not a candidate for revascularization

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What are closed (flap) amputations?

  • Usually elective and performed when infection is not present

    • Creation of a weight-bearing residual limb (stump)

    • Covered with a sutured flap of skin

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What is an open (guillotine) amputation?

  • Performed when infection is present or suspected (or in an emergency situation as traumatic)

    • Surface of residual limb is left open

    • Second surgery needed for closure after infection resolves

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What is a disarticulation?

  • Amputation through a joint

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What is nursing management for amputations?

  • Control underlying disease/problem

  • Pain control

  • Cope w body image changes

  • Achieve maximum rehab potential

  • Make appropriate lifestyle adjustments

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What are preop nursing managements for amputations?

  • Educate patient

    • Phantom limb pain

    • Compression bandages

    • potential prosthesis

    • Mobility and rehab expectations

  • Strengthening exercises

    • Build arm strength

  • Provide emotional support

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What are postop nursing managements for amputations?

  • Prevention of complications

  • Treat pain

  • Assess for signs of bleeding or oozing

    • surgical tourniquet at bedside

  • Elevate stump for first 24hrs, then place flat on bed (depend on surgeon)

  • ROM exercises and early ambulation with assistive devices

  • Compression bandage

    • Reduce edema, increase healing, decrease pain, promote shrinkage

  • Limit hip flexion

    • Position on abdomen 3-4 times a day

    • Limit time sitting in chair

  • Rehab Needs

  • Monitor limb

  • Manage coping

  • Provide family support

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What are risk factors of low back pain?

  • Lack of muscle tone

  • Obesity

  • Poor posture

  • Smoking

  • Pregnancy

  • Stress

  • Spinal abnormality

  • heavy lifting, prolonged sitting

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How to diagnose low back pain?

  • History and physical exam

  • MRI and CT

  • X rays

  • Myelogram

  • EMG

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