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MedSurg study guide

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Med-surg exam 3 / Neuro study guide Brain  Role: coordinate and organize the functions of all other body systems.  2 main divisions: CNS (brain and spinal cord) + PNS (cranial and spinal nerv... es and autonomic system) Neuro Assessment  Health History o Common symptoms: assess OLDCARTS  Pain, dizziness/vertigo, seizures, muscle weakness, abnormal sensation, visual disturbances, visual changes (double vision, flashing lights)  Past health history (head trauma), family history, and social history (elicit drug use) (recall from HA)  Physical Exam o Mental status (LOC) o Motor ability + muscle strength  *Be aware of the normal aging process the nervous system undergoes* Common Neuro Diagnostic Tests  Imaging studies o Computed tomography (CT) scan  Gold standard for strokes o Magnetic resonance imaging (MRI) o Positron emission tomography (PET) o Skull and spinal x-rays  Angiographic studies o Cerebral angiography  Electrophysiologic studies o Electroencephalography (EEG)  Gold standard for seizures o Electromyography (EMG)  Look at diagram on this slide for diagnostic tests. Altered LOC  Altered LOC is not a disorder, it’s a change in function due to different phenomenon’s we experience due to a neurologic issue. o LOC can be impaired by any disorder that affects cerebral hemisphere of brain: stroke, head injury, trauma, drug OD  Gauged on a continuum from full cognition to coma o Used the Glasgow Coma Scale: eye opening, motor response, and verbal response o Range 3-15  3: severe impairment  <9: coma levels  15: no impairment  Clinical manifestations  Nursing Interventions o Maintain airway: elevate HOB, suction, oral hygiene (risk for aspiration), tracheostomy (trach care), ventilator o Safety: padded side rails, low boy beds, bed alarms, sitter in the room o Fluid and nutrition status: IV fluids, especially if in coma, monitor I/O, feeding tube if LOC does not increase. o Skin integrity: turn client, inspect skin, assess for urine leakage and stool leakage.  Repositioning: lift patient to prevent shearing. Increased Intracranial Pressure  Normal ICP: 0-10 mm Hg; 15 mm Hg is the upper limits. *Anything over 15 is TOO HIGH*  Inverse relationship: As ICP increases, cerebral blood flow decreases.  Most often associated with head injury, but also caused by brain swelling, epilepsy, and meningitis.  Increased ICP results in: o Decreased cerebral perfusion o Cerebral edema o Displace brain tissue: also called herniation. o Destroy brain cells  Continual ICP leads to impaired neuro function leading to altered LOC: drowsy and slurred speech. o Abnormal posturing occurs = decorticate and decerebrate positioning seen. This is an EMERGENCY!  Osmotic diuretic will be ordered to quickly reduce edema. i.e. Mannitol  Also, restrict fluids, drain CSF, control fever because fever and shivering can increase ICP due to cellular metabolic demands. Also, maintain BP and O2.  Once stable, look for underlying cause. o If not corrected, client will become comatose. Seizures  Seizure: sudden abnormal electrical discharge [Show More]

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