NUR 265 Exam 3 Review Complete Study Guide Latest with Complete Solutions.

NUR 265 Exam 3 Review Complete Study Guide Latest with Complete Solutions. NUR 265 Exam 3 Review MENINGITIS Patho: Inflammation of the inner meninges Usually caused by: 1. Autoimmune reaction 2. Adverse reaction to medication or procedure (Spinal or Brain) direct route of entry 3. Infection: a. Bacterial: Most common Strep. Pneumoniae and Neisseria MeningitidsHighly contagious (see risks) b. Viral: Most common herpes, Varicella (chicken pox/shingles) c. Fungal: Usually seen in pts w/ AIDs Risks: - Infections of eye, ear, mouth (like a tooth abscess) and neck are at increased risk a/r close anatomic proximity - Pts ages 16-21 at highest risk for bacterial meningitis. Vaccinate @11-12 y/o then booster @16. - Pts living in high density populations (dorms, barracks, crowded living areas) have increased risk for bacterial meningitis as well. Initial or booster vaccination is advised for these adults. - Pts who are immunocompromised AIDs, Cancer Rx tx, or pts receiving immunosuppressant tx for organ transplant or autoimmune disease. S/S: - Classical Triad: Headache, Fever, Neck pain (nuchal rigidity) - Kerning’s sign (may or may not be present) back pain when flexing knee beyond 90 degrees w/ pt in supine position - Brudzinski’s sign (may or may not be present) flexing the head when pt is in supine position results in automatic flexion of legs and/or hips - Photo and Phonophobia - Rhinorrhea (nasal discharge of CSF basal skull fracture) or Otorrhea (ear discharge same as rhinorrhea) - ICP changes in mental status/LOC and/or orientation can progress to seizures - Systemic Inflammatory response Coagulopathy changes in vascular status if thrombi forms DIC, gangrene - Other usual s/s of infection may or may not be present (like tachycardia, fever, chills etc.) Dx: CT – if pt is >60, immunocompromised, or have s/s of ICP then CT first all other LP. LP – If viral CSF is usually clear and if bacterial usually cloudy. All other findings such as glucose, WBC and protein are usually the same. Management: - Priority = Airway Breathing and Circulation + Monitoring + documenting neuro status (q2-4h) - Seizure precautions - BS AB tx until LP results then specific Rx tx. - Managing ICP Mannitol and Antiepilectic rx - If bacterial meningitis DROPLET + STANDARD - prophylaxis tx for close contact - Decrease stimuli + keep HOB elevated at 30 degrees. ENCHEPALITIS Patho: Inflammation of the brain and surrounding meninges. Most commonly caused by viral infections such as Herpes (HSV1) and Varicella S/S: -Changes in mental status such as agitation, acute confusion, irritability or personality/behavioral changes -ICP -Neurological deficits vision loss, seizures, muscle weakness, and paralysis. **these changes may last for weeks and may be permanent. - photo and phonophobia Management: -Priority = Airway. Turn cough and deep breathe q2h UNLESS ICP present. If on vent and s/s of ICP suction -Monitor Neuro Status: -Glasgow Coma Scale max score of 15, min of 3 (totally dependent) Any change >2 notify MD -Any change in neuro status such as increasingly dilated pupils or decreased responsiveness to light, new onset of bradycardia, widening pulse pressure (basically s/s of increasing ICP) or irregu