Med Surg 2 Final Study Guide Primary Concepts Of Adult Nursing II (Nova Southeastern Uni, Exams of Nursing

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Med Surg 2 Final Study Guide

Primary Concepts Of Adult Nursing II (Nova

Southeastern University)

What’s in bold she verbally mentioned

20-Respiratory

Asthma (3 questions)

*Bronchodilator teaching- appropriate time?

• Can used prophylactic before activity such as walking and eating
• Prescribed for PRN or for regular basis
• Proper usage: exhale first, seal lips around pump, press down and inhale and hold for 10 seconds, repeat puffs as directed but allow 15-30 in between.

Asthma patho

• Chronic inflammatory disease, reversible condition, causes airway hyper responsiveness, mucosal edema and mucous production.
• Inflammatory response occurs= mast cells, macrophages, t lymphocytes, neutrophils, eosinophils, IgE(causes direct bronchoconstriction)

S/S

• Cough, chest tightness, wheezing (on expiration), dyspnea

*Monitor airway patency due to mucous from the inflammatory process.

Status Asthmaticus- is when an asthma attack doesn’t respond to therapy. Rapid onset severe and persistent.

Atelectasis

*prevention (post op)

• Atelectasis can arise from abdominal/thoracic surgery o Teach pt. cough deep breathing (splint pillow on incision) o Incentive spirometer o Frequent turning o Ambulating o PEEP for pt. that cannot perform the basic measures (listed above)- positive end expiratory pressure.

Pneumonia

*Nursing Interventions

• Remove secretions (if pt. cant cough, possible suctioning)
• Encourage hydration/humidifier-lossens secretions
• High humidity face mask
• Encourage coughing
• Lung expansion maneuvers- IS, deep breathing and coughing

• Airway clearance by adequate hydration, and proper posture
• Medication adherence
• Promoting activity adequate nutrition- bc of coughing pts may feel fatigue, small frequent meal and liquid supplements aid in caloric requirements
• Preventing transmission-monitor for fever, signs of worsening or spread of disease
• Place Pt. in a negative air pressure room

*INH

• Can be used prophylactically for people at risk for TB 6-12 month’s daily dose
• Monitor liver enzymes, BUN, & creatinine monthly
• Sputum cultures monitored for AFB (acid fast bacilli)
• Monitor for fevers b/c this will determine if there is resistance to abx TX
• Take on empty stomach b/c food interacts with absorption
• Avoid tyramine and histamine for ex. Tuna, aged cheese, red wine, soy sauce, and yeast extracts.

Respiratory distress symptoms

• Hypoxia due to due poor gas exchange (oxygen starved), confusion is a result.

Bronchoscopy

• Before the procedure, informed consent is obtained.
• NPO 4-8 hours before the test.
• Explain procedure,
• Administer preoperative med,
• Pt. must remove dentures.
• After the procedure pt. is still NPO until cough reflex returns.
• Check LOC, respiratory status, signs of hypotension, tachycardia.
• A small amount of blood-tinged sputum and fever is expected within the first 24 hours.
• Instruct pt. to report SOB or bleeding.

ABG’s

*Chronic vs. acute patient (compensation)

**- Chronic patients will have a compensatory response and learn to adapt with this

• Bicab: 22-
• pH: 7.35 - 7.
• PaO2: 80-
• PaCO2: 35-
• ABG levels are obtained through an arterial puncture at the radial, brachial, or femoral artery or through an indwelling catheter**

35- Cardiovascular

Dysrhythmias

• Disorders of the formation or the conduction or both of the electrical impulses of the heart

Normal Sinus rhythm

• HR 60-

Sinus bradycardia

• HR less than 60
• If symptomatic treat with atropine (0.5mg every 3-5 min , max total dosage 3mg, IV bolous) o S/S of brady shakiness hypotension and syncope
• Not symptomatic=no tx
• Try to resolve underlining cause

Sinus tachycardia

• HR 100-
• Identify the cause to reduce the symptoms
• If hemodymically unstable- synchronized cardio version needs to be done
• Vagal maneuver or adenosine (stops the heart momentarily, and resets it)

Sinus arrhythmia

• HR 60-100 (increases during inspiration and decreases with expirations)
• Rhythm: irregular
• Not treated b/c it does not cause any hemodynamic effects

PAC (premature atrial contraction)

• “heart feels like it skipped a beat”
• Can be caused by caffeine or alcohol or nicotine
• No tx if its infrequent
• If persistent more than 6 per min can cause more serious dysrhythmias such as afib
• Treat underline cause

A flutter

• Saw tooth like (p wave)
• Atrial rate 250-400 Ventricular rate 75-
• Atrial rate is fast and av node cant keep up
• TX- vagal maneuveur or adenosine (adm w/arm up and 20ml flush, bc it has a very short half life), Cardiovert to sinus rhythm

A Fib

• HR 300-600 (atrial rate) 120-200 (ventricular)
• Rhythm is highly irregular
• No P wave

• Intervention o Daily weight- same clothes same time every day o Conserve energy by balancing activities with rest periods o Restrict Na, fluid restriction o Monitor for skin breakdown due to edema (it causes decrease circulation) o Auscultate lungs for fluid overload and heart sounds o Monitor electrolytes due to diuretics (make sure they have proper kidney function) o You cant fix HF we only treat the symptoms

*Lasix and CHF

• Monitor electrolytes (k+)
• Monitor for kidney function
• Daily weight to see if meds are effective (check I/O’s)
• Give in the morning to avoid going to the bathroom all night

*CAD is atherosclerosis and that causes angina (stable and unstable) which then can lead to ACS/ MI

ACS

• Emergency situation that is an acute onset of myocardial ischemia = myocardial death (MI) if interventions do not occur ASAP

MI Interventions (select all that apply) What should the nurse do first? Have the patient sit down

MONA

• 1 st- 12 lead EKG within 10 minutes upon arrival
• Obtain labs (cardiac enzymes) Troponin
• Oxygen
• nitro, morphine, aspirin, beta blocker, ACE inhibitor within 24 hrs, bed rest for minimum 12- 24 hours

Nitro

• Is given for angina and prophylactically
• Sublingual (3 dose max, Q5 min)
• Potent vasodilator
• Stored in dark bottle (shelf life is 6 months never been opened, or 3 month if opened), metal cap, no cotton filter
• Call 911 after and wait for ambulance

Different types of angina (ischemia)

• Stable o Predictable and consistent pain occurs on exertion, relieved by rest or nitro

- Unstable o AKA: Pre-infarction angina-symptoms increase in frequency and severity and not relieved with rest or nitro

Risk for cardiovascular disease (select all that apply)

• Modifiable: Cholesterol abnormalities, tobacco use, HTN, DM, metabolic syndrome, obesity and sedentary lifestyle
• Non modifiable: family hx, increased age (more than 45 males, more than 55 for women) gender, race (mainly African Americans)

Normal Goal = <120 and <

• Prehyeprtension = 120-139 or 80-
• Stage I HTN = 140-159 or 90- o Thiazide diuretic is the first treatment of choice o Before medications try lifestyle modifications first – diet, exercise
• Stage II HTN = > or = 160 or > o Thiazide diuretic in combination with an ACE or ARB, BB, or, CCB as treatment

Simvastatin

• Lowers high cholesterol and triglyceride levels. May reduce the risk for MI, stroke, and coronary heart disease
• Normal cholesterol level: below 200 mg/dl
• Patient teaching: o Instruct patient to take medication as directed, not to skip doses or double up on missed doses. Advise patient to avoid drinking more than 1 qt of grapefruit juice/day during therapy. Medication helps control but does not cure elevated serum cholesterol levels. o Advise patient that this medication should be used in conjunction with diet restrictions (fat, cholesterol, carbohydrates, alcohol), exercise, and cessation of smoking. o Instruct patient to notify health care professional if unexplained muscle pain, tenderness, or weakness occurs, especially if accompanied by fever or malaise. o Advise patient to wear sunscreen and protective clothing to prevent photosensitivity reactions (rare). o Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional before taking any new medications. o Advise patient to notify health care professional of medication regimen before treatment or surgery. o Instruct female patients to notify health care professional promptly if pregnancy is planned or suspected, or if breastfeeding. o Emphasize the importance of follow-up exams to determine effectiveness and to monitor for side effects.

PCI

• Instruct pt. to report chest pain and bleeding or sudden discomfort from the catheter insertion site. “Leg is falling asleep” ➔ requires immediate intervention
• Monitor pt. for contrast agent-induced nephropathy by observing elevations in the serum creatinine levels. CHECK BUN AND CREAT. (Because of contrast, you want to make sure the kidneys are filtering the contrast effectively.)
• Oral and IV hydration used to flush contrast agent from urinary tract. Record I & O
• Ensure pt. safety by instructing pt. to ask for help when getting out of bed the first time after procedure, monitor for orthostatic hypotension, dizziness, and light headedness.
• **Check coag tests (PT/PTT) because it is an invasive procedure, you want to make sure they are clotting right
• ** If allergic to Iodine the study will still be done, Benadryl and Solu-cortef will be given before.
• ** If Pt. has renal problems, fluids will be give to flush out contrast
• **Cardiac Cath. Pt. will be your PRIORITY…unless you have a cardiac arrest.

HTN

*Essential and secondary

• Essential HTN- High Bp from an unidentified cause (majority of people) o Risk factors: diet, exercise, smoking stress, alcohol, age, genetics, hyperlipidemia, DM, kidney disease
• Secondary HTN - the cause of high Bp can be identified o For example: renal disease, hyperaldosteronism, pheochromocytoma, medications)

Endocarditis

*Treatment and prophylactic teaching for discharge

• Infection in the endocardium (inner most)
• By treating streptococcal pharyngitis you can prevent rheumatic fever, which can lead to rheumatic heart disease.
• Infective endocarditis occurs with prosthetic heart valves, pacemakers, or valve disorders.

Treatment/teaching

• Good oral hygiene
• Hand hygiene when dealing with long term iv lines (pic lines)
• Monitor IV sites for redness tenderness warmth swelling drainage.
• Abx adherence
• Abx therapy adm 2-6 weeks Q4hrs or continuously with IV or 1 daily IM injection.
• Monitor blood work for therapeutic effects of Abx, and blood cultures
• Tx of choice usually penicillin

• Sx interventions – valve debridement or replacement (pt. who have prosthetic valve endocarditis require valve replacement)

Valve Disorders-

• Regurgitation- when valves do not close completely, blood flows backwards through the valve
• Stenosis- when valves do not open completely, and blood flow is reduced
• Mitral Valve Prolapse - a portion of one or both mitral valve leaflet balloons back into the atrium during systole. Most people never have symptoms. Some have fatigue, sob, lightheadedness, dizziness, syncope, palpitations, chest pain, and anxiety. The first and only sign is an extra heart sound. Patient is advised to eliminate caffeine and alcohol and stop using tobacco.
• Mitral regurgitation-blood flowing back from the left ventricle into the left atrium during systole. Dyspnea, fatigue, weakness are the most common symptoms. Treatment-ACE inhibitors & ARBS
• Mitral stenosis-an obstruction of blood flow from the left atrium into the left ventricle often caused by rheumatic endocarditis. Poor left ventricular filling can cause decreased cardiac output. Symptoms: dyspnea on exertion, pulse is weak, and irregular due to a-fib. Tx: anticoagulants. Patients are advised to avoid strenuous activity, competitive sports, and pregnancy, all of which increase the HR.
• Aortic Regurgitation- flow of blood back into the left ventricle from the aorta during diastole. Arterial pulsations are visible, and dyspnea. Pt. is advised to avoid physical exertion, competitive sports, and isometric exercise.
• Aortic stenosis- progressive narrowing of the orificle between the left ventricle and aorta usually over several decades. Symptoms include dyspnea, orthopnea, pulmonary edema, dizziness, syncope, and angina. Med management is surgical replacement of the aortic valve

Mitral Stenosis-anticoagulation therapy, common dysrhythmias

• Patho: Obstruction of blood flowing from the left atrium into the left ventricle
• Most often caused by rheumatic endocarditis, which progressively thickens the mitral valve
• Clinical Manifestations: First s/s of Mitral stenosis is dyspnea on exertion. Symptoms don't start to occur until the valve opening has been reduced to one half its usual size. An enlarged left ventricle can cause pressure on the bronchial tree causing the patient to experience coughing and wheezing. Patient may have hemoptysis, Paroxysmal nocturnal dyspnea, orthopnea, palpitations, and may have recurrent respiratory infections. As a result of increased volume and pressure in the atrium, the atrium dilates and hypertrophies becoming electrically unstable in which the patient may experience atrial dysrhythmias
• Assessment: The pulse is weak and irregular because of a-fib caused by strain on the atrium. Low pitched diastolic murmur is heard in the apex of the heart
• Diagnosis: Echocardiography/EKG/cardiac cath/exercise testing are used to diagnose mitral stenosis and determine the severity

above the heart to promote circulation of the veins. Early ambulation is encouraged. Deep breathing exercises are beneficial

Arterial Disorders: arteries carry oxygenated blood to the different parts of the body

• Cause ischemia and tissue necrosis
• Progressive pathological changes to the arterial vasculature: atherosclerosis or due to acute loss of blood flow to tissue like an aneurysm rupture.
• Arteriosclerosis: muscle fibers and endothelial lining of the walls of small arteries and arterioles become thickened
• Atherosclerosis: accumulation of plaque consisting of lipid, calcium, blood components, carbs, and fibrous tissue on the intimal layer of the artery.
• Intermittent claudication: a symptom of atherosclerosis
• Arterial blood supply to a body part can be enhanced by positioning the part below the level of the heart. For the lower extremities, this is accomplished by elevating the head of the bed or having patient sit up with feet resting on the floor.
• Nurses can assist the patient with walking doing isometric exercise to promote blood flow and encourage circulation. Instruct the patient to walk to the point of pain, the rest until pain goes away and continue walking.
• Application of warm compresses to promote arterial flow instruct Pt. to avoid cold temperatures, which cause vasoconstriction.
• Ulcerations and gangrene can occur
• Elevating the extremity or placing it in a horizontal position increases the pain. Placing the extremity in a dependent position reduces the pain. Some Pt. sleeps with the affected leg hanging over the side of the bed. Some patients sleep in a recliner chair in an attempt to prevent relieve of pain.
• Assessment: cold, numb extremity and intermittent claudication is a result of reduced arterial flow. Extremity is cool, pale, and when elevated or ruddy & cyanotic when placed in a dependent position. Skin and nail changes, ulcerations, gangrene, and muscular atrophy may be seen. Bruits may be auscultated, peripheral pulses may be diminished or absent.
• Aneurysms- caused by atherosclerosis occurs mostly in white Males age 50-70. Symptoms include persistent or intermittent back or abdominal pain.

Heparin and DVT

• Indications-Anticoagulation in patients with current VTE or VTE prophylaxis in Pt. at risk. Administered subq to prevent development of DVT, or by intermittent or continuous IV infusion using weight adjusted dosing along with vitamin K antagonist. Monitor PTT, INR, and platelet count.

Raynaud’s (know the patho to be able to determine tx)

• Intermittent arterial vasoconstriction that results in coldness, pain, and pallor of the fingertips or toes.
• May be triggered by emotional factors or exposure to cold temperatures.
• Most common in women age 16-40 years old.

• Heat may be applied directly to ischemic extremity using a warmed or electric blanket; however the temp of the heat source must not exceed body temp. Even low temp could cause trauma to the tissue and cause ischemic extremities. Encourage Pt. to stop smoking!
• Clinical Manifestations: white, blue, & red color changes in the fingers or toes. Numbness, tingling, and a burning pain as the color changes. Bilateral, and symmetrical changes in toes and fingers.
• TX: Avoid stimuli, which includes cold temperatures and tobacco use because they promote vasoconstriction. Calcium channel blockers are the treatment to relieve symptoms.
• Nursing Interventions: teach Pt. to avoid stimulations that may be unsafe or stressful. Exposure to cold is minimized, when winter wear warm clothes. Pt. should avoid all forms of nicotine to help quit smoking. Pt. should be cautioned to handle sharp objects carefully to avoid injury to fingers. Educate about postural hypotension that may result from meds like Ca channel blockers used to TX Raynaud’s Phenomenon.

Coronary artery disease (prevention-low fat diets, control bp) teaching

Preventions & Teaching

• 4 modifiable risk factors: cholesterol abnormalities, tobacco use, HTN, and Diabetes
• Control cholesterol- Normal Levels o LDL- less than 100 mg/dL o Total cholesterol less than 200 mg/dL o HDL- greater than 40 mg/dL for males and greater than 50 mg/dL for females o Triglycerides less than 150 mg/dL
• Control Diet-low in saturated fat & high in fiber.
• Increase Physical Activity- engage in moderate intensity aerobic activity for at least 150 minutes per week, or vigorous-intensity aerobic activity of at least 75 minutes per week. Pt. should begin with a 5 minute warm up before stretching to prepare body for exercise, the should end exercise with a 5 minute cool down.
• Medications- Lipid lowering meds such as the Statins (simvastatin)
• Promote Cessation of Tobacco Use
• Manage HTN and control diabetes

14- Musculoskeletal

Osteoporosis (2 questions)

• Reduced bone mass, deterioration of bone matrix, and diminished bone architectural strength.
• Risk Factors: small framed, Asian, Caucasian women, Increase age, nutritional factors like low Vitamin D and Calcium, patients who have had bariatric surgery, casts, inactivity, paralysis, or other disabilities result in more bone resorption, obesity,
• Occurs in women after menopause usually by age 51 and in men later in life, its not a consequence of aging
• Pt. should reduce the use of caffeine, cigarette smoking, carbonated soft drinks, and alcohol

o A second person should be used to support the extremity when loosening the boot to inspect the skin or putting it in place

Bone CA-

o Benign tumors of the bone and soft tissue are more common than malignant primary bone tumors.

Osteoarthritis – pt. teaching

• It’s a noninflammatory degenerative disorder of the joints. Begins in the third decade of life and peaks in the fifth and sixth decades. Women mostly white or African American is most affected.
• Pain management and functional ability are goals.
• Usually they are overweight, and have sedentary lifestyle. Wt. loss and exercise are important approaches to pain and disability improvement.
• Clinical manifestations: pain, stiffness, and functional impairment. The joint pain is usually aggravated by movement or exercise and relieved by rest.
• Occurs in weight bearing joints: hips, knees, and cervical and lumbar spine. Crepitus may be palpated over the knee.
• The goals: decrease pain, and stiffness and to maintain or improve joint mobility. Exercise can prevent OA progression and decrease symptoms. Wt. loss can be beneficial. OT and PT can also help
• Risk factors: increase age, obesity, previous joint damage, genetics
• Pain- on awakening in the morning nut lasts less than 30 minutes may have palpable bony nodules. There is no synovial fluid between bones, bones are rubbing against each other
• Medical TX: apply heat, rest joint/ avoid overuse, lose wt., Tylenol, NSAID, severe cases- surgery
• Nursing Care- pain management, encourage Wt. loss, encourage gentle exercise, may need assistive devices- cane may be referred to PT

Assessment of surgical fracture repair-what are they at risk for hemorrhage and infection

Fractures (5 questions)

• Complete or incomplete disruption in the continuity of bone structure and its defined according to its type and extent.
• Clinical Manifestations: pain, loss of function, deformities, shortening, crepitus, edema and ecchymosis,
• Nursing Management of an Open Fracture- risk for osteomyelitis, tetanus, and gas gangrene. We want to prevent infection, and promote healing of the bone and soft tissue. IV ABX are administered, would irrigation and debridement are initiated. The extremity is elevated to minimize edema

20-Neurology

ICP (3questions)

• Normal ICP is 0-10 and 15 being the higher limit of normal
• The Monroe Kellie Hypothesis explains the dynamic equilibrium of cranial contents

• Theory that states that due to limited space for expansion in the skull, an increase of any one of the cranial contents (brain tissue, blood, CSF) causes a change in the volume of the others to accommodate and adjust to the limited space to prevent from intracranial pressure to rise.
• ICP is most commonly associated with head injury it can also be elevated and seen as a secondary effect from other conditions such as: tumors, hemorrhages, and toxic and viral encephalopathies. ICP from any cause decreases cerebral perfusion, stimulates further swelling, and may shift brain tissue resulting in herniation, which is a fatal event.
• Decreased Cerebral Blood Flow:

Increases in ICP will decrease cerebral blood flow causing ischemia and cell death. A rise in BP, a slow bounding pulse, and respiratory irregularities suggest increasing ICP. An increase in PaCO causes vasodilation and can lead to an increase in cerebral blood flow and increased ICP. A decrease in PaCO2 has a vasoconstrictive effect and will limit blood flow to the brain and decreased outflow will increase cerebral blood volume causing ICP.

• Cerebral Edema:

Abnormal accumulation of fluid associated with an increase in volume of brain tissue. As brain matter swells the tissues compensate for the space since there is no room for expansion (Monroe Kellie Hypothesis). Autoregulation begins to occur. Autoregulation is the brains ability to change the diameter of the major blood vessels to maintain constant cerebral blood flow. Autoregulation may be impaired in patients who have a pathologic and sustained increase in ICP.

• Cerebral Response to Increased ICP:

Cushing's response (a compensatory response that attempts to provide adequate CPP in the presence of rising ICP) presents as a rising systolic pressure, a widening pulse pressure, and bradycardia and is a late presentation of brain stem dysfunction. Perfusion may be recoverable if treated right away.

Cushing’s triad: Bradycardia, Hypertension, and Bradypnea. Once the brains ability to autoregulate becomes ineffective decompensation begins. Cushing’s triad then occurs which is a very late presentation of brainstem dysfunction that presents as hypertension, usually with a widening pulse pressure, bradycardia, and bradypnea. This leads to herniation, ischemia, infarction, and death.

• Clinical Manifestations: Earliest sign of ICP is altered level of consciousness = restlessness, confusion, or drowsiness, slowing of speech and delay in response to verbal stimulus, which progresses to stupor with response to painful stimuli and eventually stops responding to that painful stimuli and becomes comatose. At this point they begin to take posture – decerebrate, decorticate, flaccidity. If coma is profound, pupils fix and dilate, respiration slows, and patient dies.
• Complications of ICP: o SIADH: result of increased secretion of ADH. Patient has volume overload and decreased urine output. Restrict IV fluids.

o Achieving an Adequate Breathing Pattern ▪ These patients are usually vented and often receive hyperventilation therapy (blows off CO2, causes vasoconstriction & lowers ICP o Optimizing Cerebral Tissue Perfusion: ▪ Patient’s head should be kept in a neutral midline position, maintained with a C-collar if necessary to promote venous drainage. ▪ Elevation of the HOB 30-45 is good unless contraindicated. Extreme rotation and flexion of the neck are avoided. ▪ Avoid the Valsalva maneuver, which can be produced when straining on defecation should be avoided. Stool softeners should be administered but if the patient is alert and able to eat then a high fiber diet is prescribed. ▪ When moving or turning the patient in bed have the patient exhale to avoid the Valsalva maneuver. ▪ If patient is on mechanical ventilation hyper oxygenate them prior to suctioning. Do not suction more than 15 sec. ▪ Activities that increase ICP should be avoided. Patients who show Increase in ICP may need sedation before nursing interventions. ▪ Emotional stress and frequent arousal from sleep are avoided. A calm atmosphere is maintained. Environmental stimuli should be minimal. o Maintaining Negative Fluid Balance: ▪ Administration of various osmotic and loop diuretics are part of treatment protocol to reduce ICP. Skin turgor, mucous membranes, urine output, and urine and serum osmolality must be monitored to assess fluid status. If IVF is ordered, the nurse must administer at slow to moderate pace to avoid over hydration. o Prevent Infection ▪ Aseptic technique must be used at all times. o Monitor and Manage potential complications ▪ Look for S/S of increasing ICP ▪ Frequent Neuro assessments ▪ Analysis of trends

Care of unconscious pt. (4-questions on the Unconscious pt)

Nursing Assessment:

o LOC: Eye opening, verbal and motor response; pupils (PERRLA) o Pattern of Respiration: Disturbances of resp. center of brain many results in various resp. patterns. Cheyne-Stokes respirations suggest lesions deep in both hemispheres or the basal ganglia and upper brain stem. Hyperventilation suggest onset of metabolic problem or brain stem damage, and Ataxic respiration with irregularity of depth/rate indicated damage to medullary center. o Eyes: PERRLA – Unequal diameter, progressive dilation, and fixed dialted pupils suggest coma, location of lesion, increasing ICP and injury at midbrain.

o Eye Movements: Normally eye should move side to side – this is absent in deep coma. o Corneal Reflex: When cornea is touched with a wisp of cotton, a blink is the normal response, usually absent in deep coma. o Facial Symmetry: Asymmetry indicates signs of paralysis. o Swallowing reflex: Drooling vs. spontaneous swallowing. Absent in coma o Neck: Stiff Neck can indicate subaracnoid hemorrhage or mengititis. o Response of extremity to noxious stimuli: Firm pressure on a joint up the upper and lower extremity. Asymmetric response in paralysis. o Deep Tendon Reflex: Tap patellar and biceps tendons – brisk response may have localizing value, Asymmetric response in paralysis, absent in coma o Pathologic response: Firm pressure on the sole of the foot, moving along the lateral margin and crossing the ball of the foot – Flexion of the toes, especially the great toe is normal in adults. Dorsiflexion of toes indicates contralateral pathology of cortiocospinal tract – positive Babinski reflex. o Abnormal Posture: Decorticate or Decerebrate posturing – indicates deeper and more severe brain pathology, poor prognostic sign. Decerebrate is worse than Decorticate.

Nursing Interventions:

o Maintain airway – HOB at 30 degrees to prevent aspiration, suctioning with moderation o Vitals – assess baseline vitals o Safety precautions – falls precautions o Seizure Precautions – padded side rails 2-3 kept in raised position - never 4 rails o Fluid and Electrolyte balance – skin tugor, mucous membranes, intake and output trends, labs, and administering IVF as needed o Oral Care – mouth is inspected for dryness, inflammation, and crusting. Risk of parotitis if not kept clean, lip balm to protect and hydrate lips and NG tubes rotated from side to side to prevent ulcerations. o Skin and Joint Integrity – regular schedule of turning patient, no dragging or pulling of the bed and sheets, use splints or foam boats to prevent foot drop, specialty beds to protect bony prominences. o Corneal Integrity – Some unconscious patients have their eyes open so they must be protected, eye drops, cold compresses for periorbital edema. o Maintaining Body Temp: Patient should be assessed for fever or hyperthermia. Can indicate infection somewhere. Environment must be adjusted according to patients condition. Rectal or tympanic temps are recommended. o Preventing Urinary Retention: If pt. is not voiding, and indwelling cath is inserted, cath care is very import to prevent infection. Condom cath or absorbent pads can be used – maintaining skin integrity is essential. o Promoting bowel function: Stool softeners, glycerin suppository, or enemas can be used. o Providing Sensory Stimulation o Meeting family needs o Monitoring potential complications