Med/Surg Chapter 41 Flashcards

Assessment of Nervous System

• Left Temporal Lobe Damage: Educating clients requires sitting on their right side to communicate effectively, as hearing is impacted in the left ear.
• Hypoactive Reflexes: Clients with decreased reflex responses may need assistance with ambulation to prevent falls, highlighting the importance of safety in motor/sensory care.
• Diminished Touch Sensation: Clients should be instructed to visually monitor foot placement to avoid injury from terrain changes due to reduced sensitivity.
• Memory Assessment: Recent memory is confirmed by recalling verifiable recent events, like a meal, whereas other types of memory (remote or immediate) are assessed differently.
• Romberg's Sign: A positive result (swaying with eyes closed) indicates proprioceptive issues, with vision compensating for balance.
• Hyperventilation and EEG: Deep breaths cause cerebral vasoconstriction, potentially increasing seizure activity; client education should clarify this during an EEG.
• Cerebral Angiography: Post-procedure care includes assessing lower extremity pulses for circulation, and noting that bedrest is typically required post-angiography.
• Magnetic Resonance Angiography (MRA): Allergies to iodine or shellfish should be checked to assess risk for dye reactions during the procedure.
• Contrast in CT Scan: Clients with renal insufficiency require intravenous fluids to help excrete contrast medium used during scans.
• MRI Contraindications: Metal devices such as insulin pumps should be flagged as they can interfere with MRI results and safety.
• Positron Emission Tomography (PET) Scan: Advise clients to avoid caffeine before the test, as it can alter brain activity readings.
• Client Concerns: When clients express worries about caregiving roles due to neurological issues, it’s essential to explore and address specific fears before providing additional resources.
• Safety Needs in Older Adults: Ensuring clear and hazard-free paths in environments for elderly clients addresses potential sensory impairments and falls.
• Post-MRI Activity: Clients can resume normal activities immediately post-MRI as there are no dyes or radioactive materials involved.
• Pain Discrimination Assessment: If a client accurately identifies pain sensations on one side, further testing on the opposite side is warranted for comprehensive evaluation.
• Cerebellar Function Impairment: Clients should not drive due to risks associated with impaired coordination and balance.
• Delegation of Care: When delegating to unlicensed assistive personnel, emphasize the importance of guiding clients with visual impairments about their food arrangement.
• Lumbar Puncture Precautions: Skin infections near the puncture site, like shingles, necessitate communication with the healthcare provider before proceeding with the LP.
• LP Complications: Immediate communication with a provider is critical for symptoms indicating increased intracranial pressure, such as nausea and vomiting following a lumbar puncture.
• SPECT Considerations: Clients should be informed about any necessary precautions related to radiopharmaceutical agents used in scans, particularly regarding potential radioactive exposure.### Renal Function Monitoring
• Close monitoring of renal functions is necessary after certain procedures.
• Radioisotopes from SPECT are eliminated via urine; no special precautions needed post-procedure.
• Follow-up assessments of the injection site post-procedure are not required.

Decorticate vs. Decerebrate Posturing

• Decorticate posturing indicates interruption in corticospinal pathways; a sign of deterioration in condition.
• Decerebrate posturing characterized by external rotation and extension of extremities.
• Immediate notification to the healthcare team is essential for abnormal posturing assessments.

Babinski's Sign

• Babinski's sign is abnormal in clients over 2 years, indicating central nervous system issues.
• Immediate provider notification is necessary for abnormal findings related to plantar reflexes.
• Other assessments for pain and perfusion are less critical than addressing the abnormal sign.

Glasgow Coma Scale Assessment

• A score of 12 shows the client opens eyes to speech, mumbles responses, and obeys commands.
• The assessment of neurological status is vital for tracking a patient’s condition.

Clinical Manifestations from Medulla Injury

• Expect impaired swallowing, inability to shrug shoulders, and loss of gag reflex due to CNS nerve damage.
• Loss of smell and visual changes are not typically linked to medulla injuries.

Temporal Lobe Injury Assessments

• Assess for memory loss, difficulty with sound interpretation, and speech difficulties following a temporal lobe injury.
• Personality changes and taste impairments are associated with other brain regions.

Sympathetic Nervous System Stimulation

• Clinical manifestations include increased heart rate and force of contraction.
• Other signs would generally involve increased respiratory rate and blood pressure.

Urgent Communication in Neurological Changes

• Report significant changes such as a Glasgow Coma Scale score of 8, decerebrate posturing, or diminished cognition.
• These are critical indicators necessitating immediate intervention.

Preparing for Iodine-Based CT Contrast

• Confirm informed consent, assess allergies (especially to iodine/shellfish), and evaluate renal function.
• Other assessments like breath sounds or hemoglobin levels are not commonly impacted by the CT scan.

Normal Aging Changes in the Nervous System

• Slower processing time and changes in sleep patterns are normal as individuals age.
• Long-term memory loss and increased sensory perception do not typically correspond with normal aging functions.

Delegation of Care for Older Adults

• Schedule care tasks when the client is alert and encourage mobility aids such as canes.
• Emphasize patient safety by encouraging foot placement awareness while walking.
• Clinical assessments and teaching should remain responsibilities of the nurse, not delegated.