Med-surge ATI:
I. NERVOUS SYSTEM:
1. Cerebral Angiogram:
- Allows for visualization of cerebral blood vessels. A catheter is placed into an artery (usually in the groin) and
threaded up the blood vessels in the brain, dye is injected, x-ray are taken.
Pre-procedure:
NPO 4-6 hrs prior.
Assess for allergy to iodine or shellfish.
Assess kidney function (BUN, creatinine) to determine if kidneys can excrete the dye.
Post-procedure:
Check insertion site for bleeding, check extremity distal to puncture site (pulses, capillary, refill,
temperature, color)
2. EEG:
- Analyzes electrical activity in the brain. It is used to identify seizure activity, sleep disorders, behavioral changes.
1 hrs.
- Pre-procedure patient instructions:
Wash hair prior to procedure
Arrive sleep-deprived (as this increases chance of seizures)
No NPO is needed. Avoid stimulates, sedative medications 12-24hrs before procedure.
Flashing light, hyperventilate (to increase electrical activity)
3. Intracranial pressure (ICP) monitoring: RANGE 10-15 mmHg.
- Inserted into cranial cavity in the OR to measure pressure. HUGE RISK OF INFECTION.
GCS score of 8 or less or coma
SYMTOMP:
Irritability (early sign!),
Restlessness, headache, decreased LOC
Pupil abnormalities, abnormal breathing ( EX: Cheyne Stokes)
Abnormal posturing.
4. Lumbar Puncture: Cerebral Spinal Fluid (CSF)
- Used to diagnose multiple sclerosis, syphilis, meningitis, infection in CSF.
Pre-procedure:
VOID
Position pt in cannonball position on their side, or have pt stretch over table while sitting.
Post-procedure:
Pt should lay flat for several hrs→ (bedrest)
If the dura puncture site does not heal, CSF may leak, RESULTING IN HEADACHE (give pain
meds, increased fluid intake).
Epidural blood patch can be used to seal off the hole.
Slightly elevated temp
Difficulty VOIDING
5. MRI:
Allergy shellfish/iodine
Hx of claustrophobia
Remove all jewelry
No metal (pacemaker, orthopedic joints, artificial heart valves, IUDs, aneurysm clips).
Earplugs can be provided, as MRIs are loud.
6. Pain
Nociceptive pain Neuropathic pain
- Damage/inflammation of tissues ( NOT part of CNS). - Damaged nerves.
- Throbbing, aching, and localized. - Shooting, burning, “pins and
- 3 types: needles”
Somatic: - MEDS: antidepressants, muscle
Visceral: internal organs. relaxants.
Cutaneous: skin, subcutaneous tissue.
, 7. Analgesics:
Non-opioid Opioid (meperidine)
- Mild → moderate pain - Moderate→ severe
- Acetaminophen NOT exceed 4g/day. - S.E: constipation, hypotension, urinary
- Monitor for salicylism w/aspirin (SX: retention, N/V, sedation, respiratory
tinnitus, vertigo) depression.
- WITH FOOD - Naloxone is antidote.
- RISK OF BLEEDING - Administer around the clock (vs PRN)
- Cause ringing of the ears - Instruct the client to void at least q4h to
decrease the risk of urinary retention
REPORT:
- Oversedation (sleep through the day)
Risk for respiratory depression.
8. Meningitis:
- Prevention:
MCV4 vaccine is given to students living in dorms
- SX:
Headache, nuchal (neck) rigidity, photophobia, N/V, positive Kerning’s and Brudzinski’s signs, fever,
altered LOC, tachycardia, seizures.
Weight loss
- Diagnosis:
CFS analysis
Bacteria will have cloudy CSF, decrease glucose content.
Viral will have clear CSF.
Elevated WBC and protein for both types.
- Nursing care:
DROPLET precautions until antibiotics are administered for 24hrs.
Quiet room, low light, HOB 30, monitor increased ICP.
Avoid coughing/sneezing, seizure precaution.
AVOID photophobia.
- MEDS:
Antibiotics, anticonvulsants (EX: phenytoin)
9. Seizures:
- Uncontrolled electrical discharge of neurons in brain
Epilepsy= chronic seizure (2 or more)
- Risk factor:
Fever, cerebral edema, infection, toxin, exposure, brain tumor, hypoxia, alcohol/drug withdrawal, fluid or
electrolyte imbalances.
- Triggering factors:
Stress, fatigue, caffeine, flashing lights.
- Types:
Tonic Clonic: 3 phases
Tonic: stiffening of muscles, LOC
Clonic: 1-2 min for rhythmic jerking of extremities.
Postictal: confusion, sleepiness.
Absence:
LOC for a few seconds.
Blank staring, eye fluttering, lip smacking, picking at clothes.
Myoclonic:
Brief stiffening of extremities.
Atonic:
Loss of muscle tone, results in FALLING.
Status epilepticus:
Repeated seizure activity within 30 min, or a single seizure more than 5 min.
,- Diagnosis: EEG
- Nursing care:
DURING:
Turn the pt to the side (priority)
Greatest risk for hypoxia from impaired airway.
Prevent aspiration.
Loosen restrictive clothing
DO NOT insert airway or restrain pt
Document/onset/duration of seizure
POST:
Check vital, neurological, reorient.
Seizure precaution, determine possible trigger.
- MEDS:
Anti-seizure => phenytoin
- Surgeries:
Vagal nerve stimulator, craniotomy to remove brain tissue causing seizures.
10. Parkinson’s Dz
- Too little dopamine and too much acetylcholine.
- Sx:
Tremor, muscle rigidity, slow/shuffling gait, bradykinesia (slow movement)
Masklike expression, drooling, difficulty swallowing.
- Nursing care:
Monitor swallowing/food intake
Thicken food, sit upright to eat.
Suction available, ROM, and exercise, assist w/ADLs
- MEDS:
Levodopa/carbidopa (increases dopamine levels)
→ sudden onset of sleep, drowsiness and dizziness.
→ AVOID driving.
→ amantadine (increasing the release of dopamine)
Benztropine (decreases acetylcholine levels)
11. Alzheimer’s Dz:
NON-REVERSIBLE dementia.
Memory loss, problem with judgment, and changes in personality.
difficulty with recent memory, swallowing and walking, impaired learning, and depression.
Nursing care:
Maintain structured environment.
Easy to read clocks with plain background (minimize confusion)
Explain how to complete a task before.
Place completed outfits on hangers and allow the client to select which one to wear each day.
Short directions, repetition.
Avoid overstimulation, use single-day calendar (with days).
Frequent reorientation, maintain routine toileting schedule.
Home safety:
Remove scatter rugs
Door locks, good lighting (stairs)
Mark step edges w/colored tape, remove clutter.
MEDS:
Donepezil (prevents breakdown of Ach, improves ADLs)
Manage sx (antipsychotics, antidepressants, anti-anxiety)
12. Multiple sclerosis:
Autoimmune disorder where plaque develops in white matter of the CNS.
Onset 20-40 yrso. More in WOMEN.
Characterized by periods of relapsing and remitting.
, Triggers:
Temperature extremes, stress/injury, pregnancy, fatigue.
Vitamin D deficiency.
Sx:
Eye problems (diplopia/nystagmus).
Muscle spasticity and weakness, bowel/bladder dysfunction
Cognitive changes, ear problems (tinnitus/hearing issues)
Dysphagia, fatigue.
N.C:
Speech pathologist will be performing a swallowing study (prevent aspiration)
Encourage pt rest before meal (weakness and fatigue)
Adequate vitamin D
Increased dietary fiber (constipation)
Liquids should be thickened to reduce aspiration.
13. Amyotrophic lateral sclerosis: (ALS)
Degenerative neurological disorder of upper and lower motor neurons, resulting on progressive paralysis.
Eventually causes respiratory paralysis within 3-5 years. Cognitive function not impacted.
NO CURE
SX:
Muscle weakness, atrophy
Nursing care:
Maintain patent airway
Suction/intubates
Monitor for pneumonia, respiratory failure.
MEDS:
Riluzole→ slows deterioration of motor neurons, extend pt’s life 2-3 months.
14. Myasthenia Gravis (MG):
Autoimmune disorder => severe muscle weakness=> antibodies that interfere with Ach at neuromuscular
junction (NMJ).
Characterized by periods of exacerbation and remission.
Associated with thymus hyperplasia.
Symptoms:
Muscle weakness (worse w/activity)
Diplopia, dysphagia, impaired respiration
Drooping eyelids (Ptosis)
Incontinence
Diagnosis:
Administer edrophonium=> increased Ach at NMJ
Symptom improve=> it is MG
IF NOT=> cholinergic crisis (Atropine is antidote).
Nursing care:
Maintain air way, REST
Provide small/frequent/high-calorie meals
Sit upright while eating, thicken liquids
Administer lubricating eye drops
Tape eyes shut at night (prevent damage to cornea)
MEDS:
Anticholinesterase agents (pyridostigmine or neostigmine)
→ 45-60 mins before meal (prevent aspiration)
Immunosuppressants.
Procedures/surgeries:
Plasmapheresis→ removes antibodies from plasma.
Thymectomy→ removal of thymus.
15. Headache:
Migraine headaches Cluster headaches
