Adult 2 Study Guide PDF

Adult 2 Study Guide -- CRAM Flashcards **Nervous System & Neuro Assessment** **Sympathetic Nervous System (\"Fight or Flight\")** - **Responsible for**: Physical reactions to stress, including elevated heart rate, dilated pupils, increased breathing rate, and the release of adrenaline....

Adult 2 Study Guide -- CRAM Flashcards **Nervous System & Neuro Assessment** **Sympathetic Nervous System (\"Fight or Flight\")** - **Responsible for**: Physical reactions to stress, including elevated heart rate, dilated pupils, increased breathing rate, and the release of adrenaline. **Parasympathetic Nervous System (\"Rest and Digest\")** - **Responsible for**: Decreasing heart rate, steady breathing, and promoting digestion and restorative processes. **Glasgow Coma Scale (GCS) and AVPU** **GCS Components**: 1. **Eye Opening** 2. **Verbal Response** 3. **Motor Response** **AVPU Mnemonic**: - **A**: Awake - **V**: Responds to verbal stimuli - **P**: Responds to painful stimuli - **U**: Unresponsive **Neuro Status & ICP Monitoring** **Assessing Pupils (PERRLA)**: - **PERRLA**: Pupils Equal, Round, Reactive to Light and Accommodation. **ICP Influences**: - **3 Components**: Brain tissue, cerebrospinal fluid (CSF), and blood. **Best Position for ICP Management**: - **Head of Bed (HOB)**: Semi-fowler\'s to promote venous return and reduce ICP. **Why manage oxygen requirements?** - Hypoxia and hypercapnia lead to cerebral vasodilation, increasing ICP. **Mannitol (Osmotic Diuretic)**: - **Purpose**: Reduces brain swelling by pulling fluid into the bloodstream. - **Considerations**: Monitor electrolytes (especially sodium) and kidney function. **Traumatic Brain Injury (TBI) & ICP** **TBI Definition**: - **Cause**: External force that disrupts normal brain function. - **Symptoms**: Can vary from mild (brief mental changes) to severe (unconsciousness, memory loss). **Concussion Symptoms**: - Sensitivity to light, headache, dizziness, nausea/vomiting, tinnitus, loss of consciousness (\ 7.45, normal PaCO2, HCO3 increased) **22. ABG Interpretation Example 2:** - **pH:** 7.43, **PaCO2:** 29, **HCO3:** 19 - **Interpretation:** **Respiratory Alkalosis, Fully Compensated** (normal pH, CO2 low, HCO3 low) **23. ABG Interpretation Example 3:** - **pH:** 7.33, **PaCO2:** 50, **HCO3:** 29 - **Interpretation:** **Respiratory Acidosis with Partial Metabolic Compensation** (pH low, CO2 high, HCO3 compensating) **Key Concepts to Review** - **Acute Respiratory Failure (ARF):** Key symptoms include confusion, shortness of breath, hypotension, tachycardia, and hypoxemia. - **ARDS (Acute Respiratory Distress Syndrome):** Caused by conditions like sepsis, shock, and trauma. Management includes providing oxygen, supporting the respiratory system, and treating underlying causes. - **Chest Tubes:** Management involves pain control, monitoring for complications (like tension pneumothorax), and encouraging respiratory exercises. **Study Tips:** - **Understand the relationship between ABGs and acid-base imbalances.** - **Be able to differentiate between different types of shock (neurogenic, hypovolemic, etc.).** - **Know the normal ranges for CPP, MAP, and ICP.** - **Understand interventions for ARF and ARDS, including prevention and management strategies.** **Nursing Exam Study Guide** ### **Nervous System** #### Sympathetic Nervous System (\"Fight or Flight\") - Responsible for body's response to stress or threats. - Effects: Increased heart rate, dilated pupils, faster breathing, release of adrenaline. #### Parasympathetic Nervous System (\"Rest and Digest\") - Effects: Decreased heart rate, steady breathing, redirected blood flow to digestion. #### Glasgow Coma Scale (GCS) Components 1. Eye Opening 2. Verbal Response 3. Motor Response #### AVPU Mnemonic for Neuro Status - A: Awake - V: Responds to Verbal Commands - P: Responds to Painful Stimuli - U: Unresponsive #### Neuro Assessment - Eyes (PERRLA) - P = Pupils - E = Equal - R = Round - R = Reactive to - L = Light - A = Accommodation - Deviations may indicate neurological decline. ### **Intracranial Pressure (ICP) Management** - Influenced by: Brain tissue, cerebrospinal fluid (CSF), and blood. - **Head Positioning:** Semi-Fowler's (HOB 30°) for venous return. - **Neck Positioning:** Neutral to optimize venous return. - **Avoid:** Straining (Valsalva maneuver). - **Environment:** Calm and restful to minimize ICP spikes. - **Medications:** - **Mannitol (Osmotic Diuretic):** Reduces brain swelling, monitor electrolytes & kidney function. - **Phenytoin (Anti-Seizure):** Prevents seizures without sedating CNS. - **Causes of Increased ICP:** High CO2, suctioning, coughing, extreme neck/hip movements, increased abdominal pressure. ### **Traumatic Brain Injury (TBI)** - **Definition:** Disruption in brain function due to an external force. - **Concussion Symptoms:** Sensitivity to light, LOC \< 30 min, headache, dizziness, N/V, tinnitus. - **Subdural Hematoma:** Monitor for anticoagulant use. - **Intracerebral Hematoma:** Bleeding within brain tissue. - **Late Sign of Increased ICP:** Cushing's Reflex (Bradycardia, High BP, Cheyne-Stokes respirations). - **Pulse Pressure Calculation:** Systolic - Diastolic (Normal = 40 mmHg). - **Cerebral Perfusion Pressure (CPP) Formula:** CPP = MAP - ICP. ### **Spinal Cord Injuries (SCI)** - **Most Neurologically Damaging Type:** Flexion/rotation injuries. - **C1-C4 Injuries:** Respiratory system impact, loss of diaphragm function. - **Priority Assessment for C1-C4 SCI:** Airway & Breathing. #### Autonomic Dysreflexia (AD) - **Risk Period:** Days to months post-injury. - **Triggering Stimuli:** Below injury level (e.g., full bladder, bowel impaction, pressure sores). - **Priority Management:** Monitor BP, remove noxious stimuli. #### Neurogenic Shock - **Occurs Immediately Post-Injury** - **Cause:** Loss of sympathetic nervous system (SNS) control. - **Signs:** Hypotension, bradycardia, warm/dry skin. #### Spinal Shock - **VS Changes?** No major BP/HR changes, focus on loss of reflexes & flaccid paralysis. - **Differentiation from AD & Neurogenic Shock:** Onset & VS alterations. ### **Meningitis** - **Risk Factors:** Skull fractures, invasive procedures, immunocompromised patients. - **Clinical Manifestations:** Headache, stiff neck, photophobia, fever, tachycardia, seizures, red macular rash. - **Nursing Considerations:** Isolation (droplet precautions), fever reduction, minimize stimuli, monitor ICP & seizures. - **Complication:** SIADH → Monitor sodium levels. ### **Stroke (CVA)** - **Types:** - **Ischemic:** Caused by embolism or thrombosis. - **Hemorrhagic:** Caused by arterial rupture. - **Warning Signs:** Widened pulse pressure, bradycardia, Cheyne-Stokes breathing. - **Risk Factors:** HTN, DM, high cholesterol, smoking, Atrial fibrillation. - **NIH Stroke Scale:** Rapid neuro assessment. - **Left Brain Stroke:** Affects right side, leads to aphasia. - **Right Brain Stroke:** Affects left side, leads to impulsive decisions & unilateral neglect. - **Treatment:** - **Ischemic Stroke:** tPA (Alteplase) if BP \< 185/110 mmHg. - **Hemorrhagic Stroke:** Control BP (target \