Timby's Introductory Medical-Surgical Nursing: Neurologic deficit Flashcards


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1

Neurologic Deficit:

Acute Phase

What are some causes of a acute phase neurologic Deficit?

Sudden neurologic event:

Cerebrovascular Accident

Head Injury

Spinal Cord injury

2

The client present w/

Altered level of consciousness LOC

Hypertension/Hypotension

Fever

Difficulty Breathing

Paralysis

Neurologic Deficit

Acute Phase

3

Medical TX for Acute Phase of Neurologic Deficit

Stabilize the client and prevent further damage

CVA: manage hyper/hypotension w/drug therapy

Head or Spinal Cord injury: required respiratory support through mechanical ventilation or surgical intervention to stabilize the injured area or remove bone fragments, blood clots, or foreign objective.

4

What are nursing management for the Acute Phase of Neurologic Deficit?

Neurologic Assessment (evaluate the client status)

Check the need for additional medical or surgical intervention and response to treatment

Glasgow Coma Scale or Mini-Mental Status Exam

report significant changes to provider

Assesses VS and BP (ensure adequate cerebral oxygenation)

I's/O's observe for electrolyte imbalance and dehydration

report UOP <500mL/day or urinary or bowel incontinence

Begin basic rehabilitation (Position changes, Skin breakdown, and Contractures are essential )

Goal is to prevent complication that will interfere with recover function

5

Neurologic Deficit

Recovery Phase

The recovery Phase begin when the client is?

Condition is stabilized

Several days or weeks after the initial event

can last or weeks or months

6

Medical TX's for recovery phase of neurologic deficit?

Aim to keep the client stable

prevent or treating complications (Pneumonia, or further neurologic impairment)

7

What are nursing intervention for neurologic deficit recovery phase?

work with team members to plan a rehabilitation program according to the clients abilities and limitations.

8

Review Table 40-1 Domain of neurologic impairment

Review Table 40-1 Domain of neurologic impairment

9

Neurologic Deficit

Chronic Phase:

How long is is neurologic phase?

Long standing or For life

10

What diseases are consider to be a chronic phase of neurologic deficit?

Amyotrophic lateral Sclerosis (ALS) AKA Lou Gehring disease

Alzheimer disease

11

The client present w/ the below are in what neurologic deficit phase

little or no improvement

remains stationary

progressively worsens

Chronic Phase

12

Why does physical and Psychologic rehabilitation continue in the Chronic Phase?

Prevent pressure ulcers and muscle contractures

13

Medical TX's for Chronic Phase of neurologic deficit?

Control of BP

Physical Therapy

Dietary management

Treatment of complication related to Disuse(not being use) and immobility

Surgery is done to correct deformities or problems that developed

Ex. muscle and skin graft to close pressure ulcer removal or kidney stones(stones from the immobility)

14

What are nursing management for the chronic phase of neurologic deficit?

Focus on preventing physical and psychologic complication

15

In the Chronic phase of neurologic deficit what does rehabilitation therapy consist of?

retraining in skill like using telephone, handling money, shopping, using public transportation, maintain household, vocational training

16

Why are client in the chronic phase of neurologic deficit are transferred to skilled and long-term care facility?

When family member can't no longer care for them or the disease has worsen.

17

What are some nursing management with psychosocial issues and home management?

listen to client and family's adaptation to the client's change in functional status

Ask direct question to identify problems and needs

evaluate the clients ability to perform self-care and resume their role in the family and call on support team

take steps to help client and family to maintain a home life near normal as possible

help with getting aid for home like wheelchairs, shower chair, cane walker

encourage family to help plan for client return home

18

What coping intervention can a nurse do to help client with a Neurologic deficits disease?

Offer reassurance and emotional support for the client

provide encouragement and praise through out rehabilitation, no matter how small helps client to accept what they cannot or never will be able to do

give client time to talk about their problems, fears, and concerns

encourage client to set reachable goals will help with independence.

work with family and client to develop solution and alternatives

suggest support groups for client with neurologic deficit for emotional social and support.

19

Socialization Nurse intervention for client w/ Neurologic deficit are?

encourages socialization with others
communication difficulties may create barriers

20

What problems affect communication in neurology deficits clients?

expressive aphasia, the inability to produce language, but may be able to write information;

receptive aphasia, the inability to understand spoken or written language, but may retain the ability to understand very common words that are used most often

dysarthria, difficulty using the tongue, lips, palate, vocal cords, larynx, or breathing to produce speech

21

What interacting technique can you do for Client with Receptive Aphasia?

Gain the person's attention's

provide sensory aids such as glasses

limit environmental distractions, such as background noise

or multiple people talking

use gestures, facial expressions, drawings and pictures

speak in a normal tone of voice

use simple language on one topic at a time

22

What interacting technique can you do for Client with Expressive Aphasia?

Provide a list of words for the client's reference or use a communication board

Allow time for a response

Guess the word that the client has difficulty saying, and ask if it is correct

Do not interrupt when the client speak

admit that you do not understand

limit questions to yes or no answers

23

What interacting technique can you do for Client with Dysarthria?

Consult with a speech therapist

practice exercises recommended by speech therapist such as a whistling: blowing bubbles, balls, or through straws

Use a communication board or software

Suggest pausing briefly between words

Have the client write the word that is not understood

utilize Prosthetics such as Dental retainer

Enlist the aid of speech generating device for creating a synthetic voice

24

How should the nurse encourage socialization with the family or care team?

By discussing current events and motivate the client to response

25

Nurse allows:

the family time to deal with and accept the changes

provides the family with opportunities to talk and openly express their anger fear guilt and helplessness

The nurse way of helping the family to process the changes.

26

Client and family teaching 40- 1 page 687

Home care for clients with a Neurologic deficit

Client and family teaching 40- 1 page 687

Home care for clients with a Neurologic deficit

27

What should you do for a client with dysphasia who takes pills?

Liquid medications (in syrup form) can be an alternative

be aware that many of these contain sorbitol.

cause diarrhea if multiple medications are given in syrup form.

28

NURSING PROCESS FOR THE CLIENT WITH A NEUROLOGIC DEFICIT. 687-690

NURSING PROCESS FOR THE CLIENT WITH A NEUROLOGIC DEFICIT 687 - 690

29

NURSING GUIDELINES 40-2 and 40-3 690 page

NURSING GUIDELINES 40-2.and 40-3 690 page