Podcast
Questions and Answers
Damage to what region of the spinal cord results in tetraplegia?
Damage to what region of the spinal cord results in tetraplegia?
- Thoracic
- Cervical (correct)
- Sacral
- Lumbar
Which finding is an expected symptom of increased intracranial pressure (IICP)?
Which finding is an expected symptom of increased intracranial pressure (IICP)?
- Decreased blood pressure
- Increased level of consciousness
- Pupillary dysfunction (correct)
- Increased mental acuity
A client has loss of motor function, loss of sensation, and loss of bowel and bladder control. Which condition is most likely related to these clinical features?
A client has loss of motor function, loss of sensation, and loss of bowel and bladder control. Which condition is most likely related to these clinical features?
- Spinal cord injury (correct)
- Glaucoma
- Increased intracranial pressure
- Cataracts
Which intervention is most important for a nurse to perform to maintain the safety of a patient experiencing decerebrate posturing?
Which intervention is most important for a nurse to perform to maintain the safety of a patient experiencing decerebrate posturing?
A client reports difficulty reading small print and needing to hold reading material at arm's length. Which condition is most likely?
A client reports difficulty reading small print and needing to hold reading material at arm's length. Which condition is most likely?
A client has undergone surgery for cataract removal. What should the nurse instruct the client to avoid during the postoperative period?
A client has undergone surgery for cataract removal. What should the nurse instruct the client to avoid during the postoperative period?
A client is diagnosed with glaucoma. For which visual symptom should the nurse assess?
A client is diagnosed with glaucoma. For which visual symptom should the nurse assess?
A nurse is caring for a client with a spinal cord injury at the T6 level. Which complication is the client at highest risk for?
A nurse is caring for a client with a spinal cord injury at the T6 level. Which complication is the client at highest risk for?
What is the primary purpose of the Rinne test?
What is the primary purpose of the Rinne test?
Which nursing intervention is a priority for a client experiencing hemineglect?
Which nursing intervention is a priority for a client experiencing hemineglect?
What is the expected finding of the Weber test in a client with normal hearing?
What is the expected finding of the Weber test in a client with normal hearing?
A nurse is preparing to administer thrombolytic therapy to a client experiencing an ischemic stroke. What is the maximum timeframe from the onset of symptoms that this therapy can be administered?
A nurse is preparing to administer thrombolytic therapy to a client experiencing an ischemic stroke. What is the maximum timeframe from the onset of symptoms that this therapy can be administered?
Which of the following is the most appropriate nursing intervention for a client experiencing sensory overload?
Which of the following is the most appropriate nursing intervention for a client experiencing sensory overload?
What is the primary goal of nursing interventions for a client with increased intracranial pressure (IICP)?
What is the primary goal of nursing interventions for a client with increased intracranial pressure (IICP)?
Which condition is characterized by damage to the blood vessels of the light-sensitive tissue at the back of the eye?
Which condition is characterized by damage to the blood vessels of the light-sensitive tissue at the back of the eye?
What is the significance of a positive Brudzinski sign during a physical assessment?
What is the significance of a positive Brudzinski sign during a physical assessment?
In the context of ischemic stroke, what pathophysiological process directly leads to cerebral dysfunction?
In the context of ischemic stroke, what pathophysiological process directly leads to cerebral dysfunction?
What is the rationale for using sequential compression devices (SCDs) on a client with a spinal cord injury?
What is the rationale for using sequential compression devices (SCDs) on a client with a spinal cord injury?
Which condition involves an interruption of all motor and sensory messaging below the level of injury in the spinal cord?
Which condition involves an interruption of all motor and sensory messaging below the level of injury in the spinal cord?
A client with tetraplegia experiences severe hypertension, severe headache, nasal stuffiness, and flushing. Which complication is most likely occurring?
A client with tetraplegia experiences severe hypertension, severe headache, nasal stuffiness, and flushing. Which complication is most likely occurring?
Damage to which section of the spinal cord would most likely result in paraplegia?
Damage to which section of the spinal cord would most likely result in paraplegia?
Which assessment finding is characteristic of complete spinal cord injury?
Which assessment finding is characteristic of complete spinal cord injury?
A client with a spinal cord injury reports a pounding headache, nasal congestion, and elevated blood pressure. What is the priority nursing intervention?
A client with a spinal cord injury reports a pounding headache, nasal congestion, and elevated blood pressure. What is the priority nursing intervention?
Which nursing intervention is crucial for a client with a spinal cord injury to prevent skin breakdown?
Which nursing intervention is crucial for a client with a spinal cord injury to prevent skin breakdown?
What is the primary purpose of implementing a bowel training program for a client with a spinal cord injury?
What is the primary purpose of implementing a bowel training program for a client with a spinal cord injury?
What is the underlying cause of an ischemic stroke?
What is the underlying cause of an ischemic stroke?
Which modifiable risk factor is most directly associated with an increased risk of ischemic stroke?
Which modifiable risk factor is most directly associated with an increased risk of ischemic stroke?
A client experiencing sudden onset of right-sided weakness, facial drooping, and difficulty speaking is suspected of having a stroke. What is the priority diagnostic test?
A client experiencing sudden onset of right-sided weakness, facial drooping, and difficulty speaking is suspected of having a stroke. What is the priority diagnostic test?
What is the significance of 'permissive hypertension' in the acute phase of ischemic stroke for clients who are not candidates for thrombolytic therapy?
What is the significance of 'permissive hypertension' in the acute phase of ischemic stroke for clients who are not candidates for thrombolytic therapy?
Which nursing intervention is most appropriate for a client with hemianopsia following a stroke?
Which nursing intervention is most appropriate for a client with hemianopsia following a stroke?
What is the primary goal of acute nursing management for a client with cerebral edema?
What is the primary goal of acute nursing management for a client with cerebral edema?
Which intervention should the nurse prioritize when caring for a client with cerebral edema?
Which intervention should the nurse prioritize when caring for a client with cerebral edema?
What is a common, early sign of increased intracranial pressure (IICP) that a nurse should monitor for?
What is a common, early sign of increased intracranial pressure (IICP) that a nurse should monitor for?
Which of the following findings indicates the poorest prognosis for a client exhibiting posturing?
Which of the following findings indicates the poorest prognosis for a client exhibiting posturing?
A client with increased intracranial pressure (IICP) is receiving mannitol. What indicates that the medication is having its desired effect?
A client with increased intracranial pressure (IICP) is receiving mannitol. What indicates that the medication is having its desired effect?
Which visual disturbance is most characteristic of glaucoma?
Which visual disturbance is most characteristic of glaucoma?
A client is diagnosed with glaucoma. Which medication class would the nurse anticipate being prescribed?
A client is diagnosed with glaucoma. Which medication class would the nurse anticipate being prescribed?
What visual change is commonly associated with cataract formation?
What visual change is commonly associated with cataract formation?
Following cataract surgery, a client reports sudden, severe eye pain. What is the nurse's priority action?
Following cataract surgery, a client reports sudden, severe eye pain. What is the nurse's priority action?
Which instruction is most important for a client after cataract surgery?
Which instruction is most important for a client after cataract surgery?
What is a common symptom of presbyopia?
What is a common symptom of presbyopia?
A client reports needing to hold reading materials at arm's length to see them clearly. Which assessment tool can best assess this condition?
A client reports needing to hold reading materials at arm's length to see them clearly. Which assessment tool can best assess this condition?
What is the underlying cause of diabetic retinopathy?
What is the underlying cause of diabetic retinopathy?
What is the priority nursing action for a client with diabetic retinopathy?
What is the priority nursing action for a client with diabetic retinopathy?
A client reports difficulty hearing high-pitched sounds and has tinnitus. Which type of hearing loss is most likely?
A client reports difficulty hearing high-pitched sounds and has tinnitus. Which type of hearing loss is most likely?
What is the expected outcome of the Rinne test in a client with conductive hearing loss?
What is the expected outcome of the Rinne test in a client with conductive hearing loss?
A nurse is teaching a client about the care of a new hearing aid. Which statement by the client indicates a need for further teaching?
A nurse is teaching a client about the care of a new hearing aid. Which statement by the client indicates a need for further teaching?
What intervention is appropriate for a client experiencing sensory deprivation?
What intervention is appropriate for a client experiencing sensory deprivation?
A client reports feeling overwhelmed by the amount of noise and activity on the unit. What is the most appropriate nursing intervention?
A client reports feeling overwhelmed by the amount of noise and activity on the unit. What is the most appropriate nursing intervention?
Which of the following is the most important consideration when communicating with a client who has vision loss?
Which of the following is the most important consideration when communicating with a client who has vision loss?
When assessing a client with a suspected neurological problem, which finding during the Brudzinski sign assessment would indicate meningeal irritation?
When assessing a client with a suspected neurological problem, which finding during the Brudzinski sign assessment would indicate meningeal irritation?
Which of the following neurological assessments evaluates a client's balance?
Which of the following neurological assessments evaluates a client's balance?
A client who suffered a stroke now has difficulty forming words. Which term should the nurse use to document this finding?
A client who suffered a stroke now has difficulty forming words. Which term should the nurse use to document this finding?
Which diagnostic method is used to visualize the internal structures of the eye, such as the lens and retina?
Which diagnostic method is used to visualize the internal structures of the eye, such as the lens and retina?
A patient with a severe traumatic brain injury is exhibiting signs of cerebral edema. The physician orders hypertonic saline. Which of the following rationales BEST explains the use of hypertonic saline in this situation?
A patient with a severe traumatic brain injury is exhibiting signs of cerebral edema. The physician orders hypertonic saline. Which of the following rationales BEST explains the use of hypertonic saline in this situation?
A client with chronic glaucoma has been diligently using prescribed eye drops. At a routine ophthalmology visit, the intraocular pressure (IOP) is within the normal range; however, visual field testing reveals continued peripheral vision loss. Which of the following statements BEST explains this clinical scenario?
A client with chronic glaucoma has been diligently using prescribed eye drops. At a routine ophthalmology visit, the intraocular pressure (IOP) is within the normal range; however, visual field testing reveals continued peripheral vision loss. Which of the following statements BEST explains this clinical scenario?
A client with a history of atrial fibrillation experiences a sudden onset of right-sided hemiplegia and aphasia. Despite rapid intervention and thrombolytic therapy, the client's neurological deficits persist, and a follow-up MRI reveals a large area of infarction in the left middle cerebral artery (MCA) territory. Which of the following factors would MOST likely explain the limited efficacy of thrombolysis in this case?
A client with a history of atrial fibrillation experiences a sudden onset of right-sided hemiplegia and aphasia. Despite rapid intervention and thrombolytic therapy, the client's neurological deficits persist, and a follow-up MRI reveals a large area of infarction in the left middle cerebral artery (MCA) territory. Which of the following factors would MOST likely explain the limited efficacy of thrombolysis in this case?
Initiation of negative pressure wound therapy (NPWT) will result in:
Initiation of negative pressure wound therapy (NPWT) will result in:
Which clinical feature is associated with a complete spinal cord injury?
Which clinical feature is associated with a complete spinal cord injury?
A patient with a spinal cord injury is being repositioned in bed. Which technique is most appropriate to maintain spinal alignment?
A patient with a spinal cord injury is being repositioned in bed. Which technique is most appropriate to maintain spinal alignment?
What is the primary physiological mechanism underlying autonomic dysreflexia?
What is the primary physiological mechanism underlying autonomic dysreflexia?
A client with tetraplegia is suspected of having autonomic dysreflexia. Which assessment finding would be most indicative of this condition?
A client with tetraplegia is suspected of having autonomic dysreflexia. Which assessment finding would be most indicative of this condition?
Which intervention is most crucial during the acute phase of neurogenic shock in a client with a spinal cord injury?
Which intervention is most crucial during the acute phase of neurogenic shock in a client with a spinal cord injury?
What is the underlying cause of a thrombotic ischemic stroke?
What is the underlying cause of a thrombotic ischemic stroke?
The acronym 'BEFAST' is used to quickly identify a stroke. What does the 'E' stand for?
The acronym 'BEFAST' is used to quickly identify a stroke. What does the 'E' stand for?
A client exhibiting ataxia and vertigo may be experiencing a stroke affecting which aspect of BEFAST?
A client exhibiting ataxia and vertigo may be experiencing a stroke affecting which aspect of BEFAST?
Why is a CT scan without contrast typically the first diagnostic test performed for a suspected stroke?
Why is a CT scan without contrast typically the first diagnostic test performed for a suspected stroke?
A client with aphasia is having difficulty communicating. Which nursing intervention is most appropriate?
A client with aphasia is having difficulty communicating. Which nursing intervention is most appropriate?
What is the primary reason for allowing 'permissive hypertension' in the acute phase of an ischemic stroke (if the client is not receiving thrombolytic therapy)?
What is the primary reason for allowing 'permissive hypertension' in the acute phase of an ischemic stroke (if the client is not receiving thrombolytic therapy)?
A client who experienced a stroke has left-sided hemiplegia. Which nursing intervention is most important to prevent complications?
A client who experienced a stroke has left-sided hemiplegia. Which nursing intervention is most important to prevent complications?
Which environmental modification is most important when caring for a client with increased intracranial pressure (IICP)?
Which environmental modification is most important when caring for a client with increased intracranial pressure (IICP)?
Why is it important to avoid clustering care activities for a client with increased intracranial pressure (IICP)?
Why is it important to avoid clustering care activities for a client with increased intracranial pressure (IICP)?
Which assessment finding best indicates that mannitol is having a therapeutic effect in a client with cerebral edema?
Which assessment finding best indicates that mannitol is having a therapeutic effect in a client with cerebral edema?
A patient with a severe traumatic brain injury is exhibiting signs of cerebral edema and is being treated with hypertonic saline. Which electrolyte imbalance is the MOST critical to monitor for during hypertonic saline administration?
A patient with a severe traumatic brain injury is exhibiting signs of cerebral edema and is being treated with hypertonic saline. Which electrolyte imbalance is the MOST critical to monitor for during hypertonic saline administration?
Which of the following best describes the pathophysiology of cataracts?
Which of the following best describes the pathophysiology of cataracts?
Following cataract surgery, why are clients instructed to avoid activities that increase intraocular pressure?
Following cataract surgery, why are clients instructed to avoid activities that increase intraocular pressure?
A client tells you that they are experiencing photophobia after cataract surgery. Which intervention is most appropriate?
A client tells you that they are experiencing photophobia after cataract surgery. Which intervention is most appropriate?
Why is it important for clients with diabetes to have regular eye exams?
Why is it important for clients with diabetes to have regular eye exams?
Which intervention is most appropriate for a client experiencing sensory deprivation?
Which intervention is most appropriate for a client experiencing sensory deprivation?
A client is concerned about their hearing loss. The nurse is teaching about hearing aids. What key point should the nurse emphasize?
A client is concerned about their hearing loss. The nurse is teaching about hearing aids. What key point should the nurse emphasize?
A client is being assessed using the Romberg test. Which instruction is most important for the nurse to give the client?
A client is being assessed using the Romberg test. Which instruction is most important for the nurse to give the client?
During a neurological assessment, a nurse elicits a positive Kernig's sign. What is the MOST likely underlying condition indicated by this finding?
During a neurological assessment, a nurse elicits a positive Kernig's sign. What is the MOST likely underlying condition indicated by this finding?
A client with a history of intravenous drug use is admitted with endocarditis and develops an embolic stroke. Despite initial treatment, the client's condition deteriorates rapidly, and a CT scan reveals extensive infarction. Which factor would MOST significantly explain the limited efficacy of the interventions?
A client with a history of intravenous drug use is admitted with endocarditis and develops an embolic stroke. Despite initial treatment, the client's condition deteriorates rapidly, and a CT scan reveals extensive infarction. Which factor would MOST significantly explain the limited efficacy of the interventions?
Flashcards
Spinal Cord
Spinal Cord
Part of the CNS, carries sensory information to the brain and motor signals to the body. Responsible for autonomic regulation.
Tetraplegia
Tetraplegia
Damage to the cervical region of the spinal cord resulting in quadriplegia.
Paraplegia
Paraplegia
Damage to the thoracic, lumbar, or sacral regions of the spinal cord.
Complete SCI
Complete SCI
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Incomplete SCI
Incomplete SCI
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Neurogenic Shock
Neurogenic Shock
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Autonomic Dysreflexia
Autonomic Dysreflexia
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Ischemic Stroke
Ischemic Stroke
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Transient Ischemic Attack (TIA)
Transient Ischemic Attack (TIA)
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Decerebrate Posturing
Decerebrate Posturing
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Decorticate Posturing
Decorticate Posturing
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Increased Intracranial Pressure (IICP)
Increased Intracranial Pressure (IICP)
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Glaucoma
Glaucoma
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Cataracts
Cataracts
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Presbyopia
Presbyopia
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Diabetic Retinopathy
Diabetic Retinopathy
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Snellen Chart
Snellen Chart
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Rosenbaum Chart
Rosenbaum Chart
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Cerebral Edema
Cerebral Edema
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Cataract (Pathophysiology)
Cataract (Pathophysiology)
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Spinal Cord Function
Spinal Cord Function
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Paraplegia Cause
Paraplegia Cause
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Spinal Cord Injury Interventions
Spinal Cord Injury Interventions
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Respiratory Priority in SCI
Respiratory Priority in SCI
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Autonomic Dysreflexia Symptoms
Autonomic Dysreflexia Symptoms
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Autonomic Dysreflexia Intervention
Autonomic Dysreflexia Intervention
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BE FAST Acronym
BE FAST Acronym
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Left Hemisphere Functions
Left Hemisphere Functions
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Right Hemisphere Functions
Right Hemisphere Functions
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Stroke Diagnostic Test
Stroke Diagnostic Test
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Thrombolytic Therapy
Thrombolytic Therapy
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Thrombolytic Contraindications
Thrombolytic Contraindications
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Stroke Nursing Interventions
Stroke Nursing Interventions
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Hemineglect Intervention
Hemineglect Intervention
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Hemianopsia Intervention
Hemianopsia Intervention
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Stroke Chronic Management
Stroke Chronic Management
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Rosenbaum Test
Rosenbaum Test
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Weber's Test Technique
Weber's Test Technique
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Romberg Test
Romberg Test
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Rinne Test Technique
Rinne Test Technique
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Sensory Deprivation Interventions
Sensory Deprivation Interventions
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Sensory Overload Interventions
Sensory Overload Interventions
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Decerebrate/Decorticate Posturing
Decerebrate/Decorticate Posturing
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Cataracts Symptoms
Cataracts Symptoms
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Increased Intracranial Pressure
Increased Intracranial Pressure
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IICP Interventions
IICP Interventions
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IICP Family Education
IICP Family Education
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Brudzinski Sign
Brudzinski Sign
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Kernig Sign
Kernig Sign
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Hearing Aid Education
Hearing Aid Education
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Interventions for Vision Loss
Interventions for Vision Loss
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Assistive Devices
Assistive Devices
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Promote Safety
Promote Safety
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Education needs
Education needs
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Sensorineural Hearing Loss
Sensorineural Hearing Loss
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Conductive Hearing Loss
Conductive Hearing Loss
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NPWT Expected Outcomes
NPWT Expected Outcomes
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Nursing Interventions for cerebral edema
Nursing Interventions for cerebral edema
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Post cataract Surgery
Post cataract Surgery
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Study Notes
Sensory Perception
- Learning guides assist in exploring key concepts for course exams, ATI assessments, NCLEX, and nursing practice
- Review sensory perception
Spinal Cord Injury (SCI)
- The spinal cord is part of the central nervous system (CNS) and acts as a messenger system
- SCI carries sensory information from the body to the brain
- SCI sends motor signals from the brain to the body
- SCI is responsible for autonomic regulation, including: breathing, circulation, digestion, urinary elimination, and sexual function
Classifications of SCI
- Tetraplegia (quadriplegia) involves damage to the cervical region of the spinal cord
- Paraplegia results from damage to the thoracic region of the spinal cord and extends through the lumbar/sacral vertebrae
- Complete SCI is the interruption of all motor and sensory messaging below the level of injury
- Incomplete SCI is when motor and sensory messages are not fully interrupted
Clinical Features of SCI
- Loss of motor function
- Loss of sensation
- Loss of reflex activity
- Loss of bowel and bladder control
- Sexual dysfunction
- Diagnostics include CT scans, MRI of the spine
Complications of SCI
- Acute respiratory failure
- Neurogenic shock (initial): cervical to thoracic cord, bradycardia, hypotension
- Autonomic dysreflexia (later)
- Stool incontinence, urinary incontinence, permanent paralysis
- Pressure injury
Nursing Interventions for SCI
- Maintain spinal alignment and immobilization by immobilizing the spine with a cervical collar and using a log-roll technique
- Avoid twisting the client's torso
- Monitor the airway, respirations, and breathing effort for respiratory support and prepare for intubation
- Cardiac monitoring includes heart rate and blood pressure, and prepare to administer IV fluids for neurogenic shock
- Maintain skin integrity by turning the client every 2 hours and manage incontinence
- Provide appropriate nutritional support
- Bowel and bladder management includes intermittent catheterization, teaching self-catheterization, scheduled voiding, checking for abdominal distension, and bowel training
- Passive and/or active range of motion exercises
- DVT prophylaxis involves sequential compression devices to lower extremities and anticoagulants
- Monitor for depression
Autonomic Dysreflexia
- Complication of tetraplegia caused by noxious stimuli below the level of injury
- Examples include distended bladder, impacted rectum, and constrictive clothing
- Injuries above T6 and in cervical lesions symptoms: severe hypertension, severe headache, nasal stuffiness, flushing, and bradycardia
Interventions for Autonomic Dysreflexia
- Raise the head of the bed
- Loosen tight clothing
- Check for bladder distension or fecal impaction
- Document the event
Ischemic Stroke
- Medical emergency
- Thrombus or embolus causes an abrupt alteration in cerebral perfusion, preventing oxygen from reaching the brain (ischemia)
- Thrombus forms in the brain
- Embolus is a clot to the brain
- Cerebral edema causes further dysfunction
Risk Factors for Stroke
- Thrombotic stroke (atherosclerosis): hypertension, diabetes mellitus, smoking
- Embolic stroke: carotid artery disease (clot comes from blocked carotid arteries), atrial fibrillation (clot comes from left atrium), abnormal cardiac valves (endocarditis)
- Transient Ischemic Attack (TIA) is considered "angina" of a "brain attack" as a warning sign of stroke
- Localized ischemic event resolves
- Neurological deficits last only minutes to hours and are never detected in imaging
- Full functional recovery occurs within 24 hours
Clinical Features of Stroke
- "BE FAST" (Balance, Eyes, Face, Arms, Speech, Time)
- Balance: ataxia and vertigo
- Eyes: blurry vision, diplopia, visual field deficits
- Face: weakness, drooping, numbness
- Arms and legs: extremity numbness or weakness
- Speech and swallowing: aphasia, dysarthria, dysphagia
- Time: onset of symptoms
- Left hemisphere: analytical thought, language, reasoning, math, science, controls touch/movement on right side
- Right hemisphere: spatial processing, emotion, art, music, visualization, controls touch/movement on left side
Diagnostics for Stroke
- CT scan of the brain (no contrast to rule out hemorrhage)
- Carotid artery duplex (ultrasound)
- Electrocardiogram (ECG)
- Echocardiogram
Nursing Interventions for Stroke
- Determine the time of symptom onset
- Administer thrombolytic therapy within 4.5 hours
- Assess for contraindications: active bleeding, recent brain/spinal surgery, uncontrolled hypertension, low platelets or high PT/INR
- Permissive hypertension is allowed for non-tPA clients up to 220/120mmHg
Monitoring in ICU
- Bleeding precautions
- Frequent neuro assessments & vital signs
- Monitor signs of increased intracranial pressure
Acute Stage of Stroke
- Monitor neurologic status
- Perform bedside swallow assessment
- Suction as needed
- Elevate head of bed 15-30 degrees
- Turn to unaffected side with head positioned midline
- Passive and/or active range of motion exercises
- Prevent complications: contractures, constipation/stool impaction, pressure ulcers, DVT
- Aphasia: face the client, reduce background noise, don't shout, allow response time, ask yes/no questions
- Hemineglect: client touches and uses both sides of the body
- Hemianopsia: client moves head to scan, approach from unaffected side, place objects in visual field
Chronic Management of Stroke
- Antiplatelet agents (aspirin)
- Cholesterol-lowering medications (statins)
- Strict blood pressure control (ACE inhibitors)
- Smoking cessation
Pearson Concepts
- Module 11: Intracranial Regulation (pp. 781-787)
- Module 18: Sensory Perception (1419-1423)
Tests and Skills
Rosenbaum
- Measures near vision by assessing the client's ability to read a chart 36 cm (14 inches) away
- Screens for presbyopia by holding 35.5 cm (14 inches) away and correlates with the Snellen chart
Weber's
- Technique: vibrating tuning fork on top of the client's head
- Expected Finding: sound heard equally in both ears (negative Weber test).
Snellen
- Measures distance vision having clients stand 6m (20ft) away
- The numerator is 20 (distance in feet from the chart) with a larger denominator indicates poorer visual acuity
- Screens for myopia (impaired far vision).
Romberg
- Assesses balance by having the client stand with feet together, arms at sides, and eyes closed
- Expected finding is minimal swaying for at least 5 seconds
Rinne
Technique: vibrates tuning fork firmly against the mastoid bone and then in front of the ear canal
- Expected Air conduction (AC) sound longer than bone conduction (BC) sound; 2:1 ratio
Nursing Interventions for Clients Experiencing Sensory Deprivation
- Provide meaningful stimulation, large-print materials, amplify phones, pleasant aromas.
- Increase touch (if acceptable) with back rubs, hand holding, range-of-motion exercises, and hair care
- Ensure client has vision and hearing assistive devices
- Communicate frequently with the client
- Encourage family flowers and pets
- Provide objects with various textures
- Encourage mental engagement (crossword puzzles, whistling, reciting)
Nursing Interventions for Clients Experiencing Sensory Overload
- Minimize overall stimuli with a private room
- Reduce light and noise, offer earplugs and dark glasses
- Provide orientation cues (calendars, clocks)
- Limit visitors & reduce unpleasant odors
- Assist the client with stress reduction
- Ensure pain is adequately managed
- Schedule sleep to minimize interruptions
Abnormal Posturing
Decerebrate
- Abnormal body posture that involves the arms and legs straight out, toes pointed down, head and neck arched backward
- Indicates severe brain damage at the level of the brainstem and often indicates a poor prognosis
- Priority: Monitor neurologic status, maintain airway patency, and ensure safety
Decorticate
- Abnormal posture where the arms are bent inwards on the chest, hands are clenched into fists, legs are extended
- Suggests damage to the brain at the level of the cerebral hemispheres
- Indicates severe brain injury however is generally considered less severe than decerebrate posturing
Increased Intracranial Pressure (IICP)
- Definition: pressure inside the skull exceeds the normal range
- Findings: decreased LOC, pupillary dysfunction, motor impairment, headache, vomiting, and Cushing triad (irregular respirations, widening pulse pressure, bradycardia)
- Significance: can lead to brain damage and is a medical emergency
- Priority: Monitor neurologic status, decrease stimuli, maintain airway, elevate head, monitor vitals and ICP device readings.
Glaucoma
- Definition: eye conditions that damage the optic nerve, often due to high intraocular pressure
- Expected findings: loss of peripheral vision, eye pain, and halos around lights
- Significance: can lead to blindness if not treated
- Priority: Administer meds lower intraocular pressure and educate on regular eye exams
Cataracts
- Definition: clouding of the eye's lens, leading to decreased vision
- Expected findings: blurred vision, difficulty with night vision, and seeing halos around lights
- Significance: can lead to blindness if untreated
- Priority: Educate on cataract surgery's benefits and provide pre- and post-operative care
Presbyopia
- Definition: difficulty reading small print/needing to hold reading material at arm's length
- Finding: difficulty reading small print/needing to hold reading material at arm's length
- Significance: common condition that affects most people over the age of 40
- Priority: Educate on the use of reading glasses or contact lenses
Diabetic Retinopathy
- Definition: diabetes complication that affects the eyes, caused by damage to the blood vessels of the light-sensitive tissue at the back of the eye
- Expected findings: floaters, blurred vision, and dark areas of vision
- Significance: can lead to blindness if not managed properly
- Priority: Control blood sugar levels, schedule regular eye exams, and educate on managing diabetes
Environmental Stimuli and IICP
- Overstimulation can exacerbate IICP, leading to further complications
- Priority: Reduce environmental stimulation and avoid clustering multiple procedures
- Create a Calm Environment by dimming lights, minimizing noise, and limiting conversations
- Limit Visitors to reduce stimulation
- Maintain a Calm Manner and approach the patient calmly
- Elevate Head of Bed to 30 degrees to facilitate venous drainage and reduce ICP and avoid hyperextension or exaggerated neck flexion
- Prevent Constipation and Bladder Distention by administering stool softeners and using methods like the Credé method
- Educate family members on the importance of maintaining a quiet and calm environment
Brudzinski Sign
- Symptoms: flex head towards the chest while lying supine, positive sign is involuntary flexion of the hips and knees
- Findings: associated with meningitis, indicating irritation of the meninges
Kernig Sign
- Symptoms: hip and knee are flexed at 90 degrees, and then the knee is straightened, a positive sign is pain/resistance in the lower back/hamstrings
- Findings: positive sign suggests meningitis due to meningeal irritation
Patient Education for New Hearing Aid
- Amplify sounds but do not help clients interpret what they hear
- Amplification of sound be distracting and disturbing in a loud environment
- Use the lowest setting that allows hearing without feedback
- Clean the ear mold, use mild soap and water while keeping the hearing aid dry
- When not in use, turn it off and remove the battery to conserve battery power
- Keep replacement batteries on hand
Nursing Interventions for Clients with Vision Loss
- Call clients by name before approaching to avoid startling them
- Identify yourself and stay within clients' visual field if they have a partial loss
- Give specific info about the location and explain interventions before touching
- Before leaving, inform clients when leaving their presence
- Appraise clients' clothing and politely suggest changes
- Make audio players available
- Describe the arrangement of the food on the tray before leaving the room
Loss of Hearing and Vision
Hearing Aids and Cochlear Implants
- For severe hearing loss, these devices bypass damaged parts of the ear and directly stimulate the auditory nerve
Visual Aids:
- Magnifiers, screen readers, and Braille materials help those with vision loss
Interventions:
- Safety by ensuring a clutter-free environment with clear pathways and adequate lighting for visually impaired patients
Facilitate Communication:
- By using clear speech, facing the patient, and employing visual aids or sign language for hearing-impaired individuals
Types of Hearing Loss
Sensorineural
- Affects the inner ear, auditory nerve, or auditory pathways in the brain
- High-frequency sounds are most affected, making speech discrimination difficult, especially in noisy environments
- Common Conditions: Congenital issues, genetic factors, or acquired conditions like noise exposure or ototoxicity
- Clinical: Tinnitus (ringing in the ears) is often associated, amplifier may be disruptive
Conductive
- Disruption in sound transmission from the external ear to the inner ear
- Finding: Equal loss of hearing at all sound frequencies
- Speech discrimination remains good if the sound level is above the hearing threshold
- Common: Obstruction (e.g., impacted cerumen), infections (e.g., otitis media), perforated tympanic membrane, or ossicle issues
- often benefits from amplification by hearing aids as well as conditions like otitis media leading to temporary or permanent hearing loss if untreated.
Mixed
- Combination of conductive and sensorineural elements affecting different parts of the auditory system
- Requires a comprehensive approach to treatment, addressing both conductive and sensorineural components
Tools/Assessments/Methods for Eye/Vision Assessment
Snellen Chart
- Used to assess distance vision.
- The patient reads letters from a chart at 20 feet.
- Normal vision is 20/20
Rosenbaum Chart
- Used to assess near vision.
- The patient reads from a card held 12-14 inches away.
- Normal near vision is 14/14
Cardinal Fields of Vision
- Finding: Assesses extraocular movements.
- The patient follows a pen or finger through six fields of vision.
Ophthalmoscope
- Used to visualize internal structures like the lens, vitreous humor, and retina.
- Typically performed by a physician
Use of Negative Pressure Wound Therapy (NPWT)
- Effective for chronic, acute, and traumatic wounds that are not healing well with traditional methods and dehisced wounds, used when surgical wounds reopen
- Helps in managing partial-thickness burns that affect the top layers of skin, ulcers, pressure, and venous insufficiency ulcers, as well as flaps and grafts, assists in the preparation and healing of skin graft sites
- Outcomes: Improved wound healing, decreased hospital stay, and enhanced oxygenation and blood flow
Cerebral Edema
- Excessive fluid in the brain is caused by increased cerebrospinal fluid production, obstruction of drainage, or impaired reabsorption, masses/tumors, infection/encephalopathy, or vascular dysfunction
- Finding: Increased intracranial pressure (ICP), headache, vomiting, change in level of consciousness, motor dysfunction (decorticate or decerebrate posturing), restlessness, hyperthermia, vision changes, abnormal pupil dilation, and Cushing triad
- Maintain calm, non-stimulating environment
- Keep the head of the bed elevated to 30 degrees and head in a neutral position
- Monitor ICP, vitals, and neurological status
- Prepare for endotracheal intubation
- Administer as prescribed: Hypertonic saline, Osmotic diuretic, Stool softener, Antipyretics and Muscle relaxers
Cataract
- Clouding or opacification of the lenses impairs visual acuity and is mainly age-related, can be unilateral or bilateral
- Clinical: painless, progressive decline in vision, problem with night driving, difficulty reading, glare, and halos
- Requires surgical intervention with artificial lens implantation, performed on one eye at a time
- Postoperative: notify surgeon if vision acuity worsens, elevate head of bed, avoid activities that increase intraocular pressure Monitor for infection and wear eye patch
- Expected finding: feeling of "sand" in the eye for 6-8 weeks, and photophobia requiring sunglasses in bright light.
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