Adult Nursing Theory Test 2 (SAQ)
SAQ Consolidation
L13 Meningitis
Definition
is an inflammation of coverings (meninges) of the brain and spinal cord. Most often it is caused by a viral or bacterial infection.
Types/Transmission mode
Bacterial, Viral, Fungal
Droplet Transmission for meningococcal disease
Predisposing sites: URTI, sinusitis, open wounds, neurosurgery/Lumbar Puncture breaks
Assessment/Diagnostics
Step / Item | Explanation | Clinical Purpose |
|---|---|---|
Recent infection / travel + neuro exam | The nurse or doctor checks if the patient recently had infections (like URTI, otitis media, sinusitis) or traveled to areas with endemic meningitis. Then they perform a neurological exam to assess consciousness, reflexes, cranial nerves, and signs of meningeal irritation (e.g., Kernig’s, Brudzinski’s). | Detects possible source and neurological involvement. |
LP and CSF: Gram stain, culture, WBC/protein/glucose | Lumbar puncture (LP) collects cerebrospinal fluid (CSF) for lab analysis. The CSF is examined for: • Gram stain & culture → identify bacteria • WBC count → elevated in infection • Protein → increased due to inflammation • Glucose → decreased in bacterial meningitis (bacteria consume glucose). | Confirms meningitis and identifies causative organism. |
Spinal tap (lumbar puncture) | Another name for LP — inserting a needle into the lower back to obtain CSF. | Direct diagnostic procedure. |
Compare serum glucose | Blood glucose is measured and compared with CSF glucose. Normally, CSF glucose ≈ 60% of serum glucose. If CSF glucose is much lower, it suggests bacterial meningitis. | Helps differentiate bacterial vs viral causes. |
Care Priorities
Rapid antibiotics (bacterial): start within 30 min to prevent sepsis/brain damage.
Isolation / hand hygiene: droplet precautions for N. meningitidis.
Airway management: maintain oxygenation; altered LOC may obstruct airway.
Neuro monitoring: GCS, pupils, reflexes, signs of ↑ ICP.
HOB 30°: promotes venous drainage, ↓ ICP.
Comfort measures: reduce headache, photophobia, restlessness.
Temperature control: antipyretics/cooling to ↓ metabolic demand.
Fluid & electrolytes: prevent dehydration or SIADH; monitor I/O and sodium.
Mnemonic: “A‑I‑N‑H‑C‑T‑F” → All In Nursing Helps Control Temperature & Fluids
L14 Seizures
⚡ Definition
Seizure: sudden, uncontrolled electrical disturbance in the brain causing changes in behavior, sensation, or consciousness.
Epilepsy: chronic condition with recurrent, unprovoked seizures.
Status epilepticus: continuous or repeated seizures lasting >5 min without full recovery — medical emergency.
Mnemonic: “Seizure = Sudden Spark in the Brain”
🧩 Seizure Phases
Phase | Description | Key Features |
|---|---|---|
Aura | Warning sensations before seizure | Mood change, déjà vu, visual/smell/taste disturbance |
Ictal | Active seizure phase | Intense, chaotic neuronal activity; tonic‑clonic movements |
Post‑ictal | Recovery phase | Confusion, tiredness, headache, nausea, weakness, injury risk |
Mnemonic: “AIP → Aura, Ictal, Post‑ictal”
🧠 Types of Seizures
Type | Description | Key Signs |
|---|---|---|
1. Generalized tonic‑clonic | Loss of consciousness → tonic stiffening → clonic jerking | Post‑ictal confusion |
2. Absence | Brief staring spells, impaired awareness | No post‑ictal confusion |
3. Focal aware | Localized symptoms, preserved consciousness | Twitching, sensory changes |
4. Atonic | Sudden loss of muscle tone (“drop attack”) | Fall risk |
Mnemonic: “GAFA” → Generalized, Absence, Focal, Atonic
🩺 First Aid: “STAY–SAFE–SIDE–STAY”
S – Start timing the seizure
A – Avoid hazards; do not restrain; protect head
F – Face sideways if not awake; keep airway clear; nothing in mouth
E – Ensure you stay until recovery; document; seek help
Mnemonic: “STAY SAFE SIDE STAY” → Stay calm, Safe environment, Side position, Stay till recovery
🚨 Status Epilepticus Management Priorities
Medical emergency: seizure >5 min or repeated without recovery
ABCs: airway, breathing, circulation
Pulse, high‑flow O₂, bedside glucose, IV access, ECG, history, neuro assessment
Administer benzodiazepines (e.g., diazepam, lorazepam) for prolonged seizures
Monitor respiratory and circulatory effects
Mnemonic: “ABCDE‑B” → Airway, Breathing, Circulation, Dextrose, ECG, Benzodiazepine
🧠 Assessment Focus
Identify triggers (infection, stress, flashing lights, missed meds)
Observe duration, type, and recovery
Document aura, movements, LOC, post‑ictal state
Maintain safety and airway patency
Mnemonic: “T‑D‑A‑S” → Triggers, Duration, Aura, Safety
💊 Nursing Priorities
Maintain airway and oxygenation
Protect from injury during seizure
Monitor vitals and neuro status
Administer prescribed anticonvulsants
Educate patient/family on medication adherence and safety precautions
Mnemonic: “A‑P‑M‑A‑E” → Airway, Protect, Monitor, Administer, Educate
L15 Care of Patients undergoing Neurosurgery
🧠 Overview
Neurosurgical nursing focuses on pre‑operative preparation and post‑operative monitoring to prevent complications and ensure optimal recovery.
Key goals: maintain airway, cerebral perfusion, and neurological stability.
Mnemonic: “Brain Care = Before & After”
🩺 Pre‑operative Care
Baseline assessments: vitals, blood work, coagulation profile, ECG, CXR, GXM, fasting.
Medication review: stop selected anticoagulants/antiplatelets as ordered.
Consent & investigations: CT/MRI, pre‑op checklist.
Patient/family teaching: explain procedure, post‑op expectations, and safety precautions.
Mnemonic: “V‑M‑C‑T” → Vitals, Medications, Consent, Teaching
🚨 Immediate Post‑operative Focus
Priority | Key Actions | Rationale |
|---|---|---|
Airway & ventilation | Monitor GCS (<8), gag/cough reflex, cranial nerve function | Prevent hypoxia and aspiration |
Haemodynamics | BP, SpO₂, ECG, ABG, electrolytes, glucose | Maintain cerebral perfusion |
Neuromonitoring | GCS, pupils, cranial nerves, reflexes, motor power, ICP | Detect early neurological deterioration |
Mnemonic: “AHN” → Airway, Haemodynamics, Neuro checks
⚠️ Complication Watchlist
Category | Examples | Nursing Focus |
|---|---|---|
Intracranial | Raised ICP, cerebral edema, haemorrhage, hydrocephalus, pneumocephalus | Monitor neuro signs, ICP, pupils |
Neurological | Seizures, delayed cerebral ischemia, CNS infection | Seizure precautions, aseptic technique |
Systemic | Hypoxia, BP extremes, glucose derangement, hyperthermia, thromboembolism | Maintain oxygenation, control vitals, prevent DVT |
Mnemonic: “INS” → Intracranial, Neurological, Systemic
💊 Nursing Care Priorities
Maintain airway and oxygenation.
Monitor neuro status and ICP.
Control BP, temperature, and glucose.
Prevent infection and thromboembolism.
Educate patient/family on recovery and precautions.
Mnemonic: “A‑N‑C‑P‑E” → Airway, Neuro, Control, Prevent, Educate
🧩 Key Nursing Reminders
Keep HOB 30° unless contraindicated.
Avoid neck flexion or straining → prevents ↑ ICP.
Ensure sterile dressing care for cranial wounds.
Report sudden neuro changes immediately.
Mnemonic: “HEAD” → Head up, Eyes watch pupils, Aseptic care, Detect changes