NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults, Exams of Nursing

Download NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults and more Exams Nursing in PDF only on Docsity! lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR lOMoARcPSD|16870840 • DKA o s/s ▪ Elevated bgl > 250 ▪ Deep rapid breathing- kussmaul ▪ Ketonuria ▪ Tachycardia ▪ Hypotension ▪ PH <7.3 ▪ Bicarb <18 ▪ Dehydration symptoms ▪ Polydipsia o Assessment ▪ Check urine for ketones when bgl > 240- possible question – mentioned during review o Prevention ▪ Increased fluids 2-3 L /day- possible question – mentioned during ▪ Take insulin when sick ▪ Check blood sugar q 2-4 hr - possible question – mentioned during ▪ If unable to eat solid food- Gatorade - possible question – mentioned during o Interventions ▪ Cc headache, abd pain, hyperglycemia- give pain meds- assess urinary output- what is priority action? Notify dr possible question – mentioned during review ▪ Isotonic fluids ▪ Insulin • Potassium must be >3.3 because insulin drives potassium into the cells and serum potassium can drastically decrease ▪ D5W • When bgl falls to 200 give D5W and .45 NS and decrease insulin o Prevents hypoglycemia o Treatment goals ▪ Reverse dehydration ▪ Reverse ketoacidosis ▪ Lower blood glucose with insulin lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR • Goal is to have a drop of bgl 50-70 / hr ▪ Replenish electrolytes o Nursing Interventions ▪ I/O- monitor kidney function ▪ V/S , lung sounds, - monitor for s/s fluid overload ▪ Monitor electrolytes • Especially K and phosphate • SIADH- fluid overload= hyponatremia o Urine Chemistry ▪ Concentrated urine ▪ Specific Gravity >1.03 ▪ Low serum osmolality <275 ▪ High urine osmolality >100 • Water retention but not solute retention ▪ Sodium in urine- high • Water retention but not solute retention ▪ Serum sodium- low ▪ U/O- reduced o Treatment ▪ Fluid restriction 500-1000 ml / day ▪ Slow Na replacement • To prevent dehydration ( 8meq/ 24 hr) • In severe cases only ▪ Hypertonic fluids • 3% and 5% saline ▪ Vasopressin receptor antagonists ▪ Diuretics o Nursing Interventions ▪ Maintain fluid restriction o Treatment goals ▪ Restore fluid and electrolyte balance lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR ▪ Decreased activity o Middle stage- weeks before death ▪ Decline in mental status ▪ Increased sleep ▪ Decreased body temp and bp ▪ Irregular pulse and respirations ▪ Speaking slows ▪ Skin color changes o Late stage- hours before death ▪ Brief surg of energy ▪ Coma ▪ Cool and mottled extremities ▪ Cheyne stokes resps o Hospice Care ▪ Terminal illness with <6 months to live ▪ Palliative rather than curative treatment ▪ Highest priority is maximizing quality of life ▪ Death with dignity • ARDS- pg 526 o s/s ▪ Refractory hypoxemia ▪ Bilateral pulmonary infiltrates ▪ Exudative phase • 24-48 hr after injury • Release of inflammatory mediators causing fluid to move from capillaries to interstitial space and alveoli • Hyperventilation • Tachycardia • Hypoxemia ▪ Proliferative phase • Damage continues as neutrophils are released as well as other toxic mediators lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR • Lungs become stiff and noncompliant • Increased work of breathing • Hypoxemia worsens • Hypercarbia • PIP can rise if on a vent ▪ Fibrotic phase • Fibrosis and scarring in lung tissue • Pulmonary hypertension • Leads to right sided heart failure • Decreased preload o Decrease bp and cardiac output • Severe VQ mismatch ▪ Findings (ABGs) • PaO2 – LOW • PACO2 HIGH • PH – LOW • PE- PaCo2- low- because it obstructs the vessels and not the airways o Assessment ▪ High flow o2 and no change in spo2- refractory hypoxia- ARDS- possible question – mentioned during review ▪ After intubation- check placement FIRST- definitive- XRAY- possible question – mentioned during review o Treatment ▪ Mechanical ventilation ▪ Prone positioning ▪ ATB ▪ Fluids and nutrition ▪ ABG analysis ▪ Normal pH (acid)7.35-7.45 (base) ▪ Normal PaCO2 (acid)45-35(base) Respiratory ▪ Normal HCO3 (acid) 22-26 (base) Metabolic lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR • Describe normal ECGs o Rate 60-100 o PR Interval (0.12 - 0.20 seconds) o QRS (0.06-0.10 seconds) o QT interval (.32-.42 seconds) o Regular o P wave before each QRS and normal • Sinus Brady o Same as above but rate <60 • Sinus tachy o Same but rate >100 < 160 • SVT- supraventricular tachycardia o Rate 160-250 o Regular Rhythm o P waves lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR • Atrial Fibrillation (afib) o Rate can be normal, rapid, or slow o Irregularly irregular o No P waves present o No PR interval o QRS normal but occur at irregular intervals • Monomorphic Ventricular Tachycardia o Rate 110-250 o Regular Rhythm o P waves buried in QRS o QRS > 0.12 and bizarre lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR o A= monomorphic o B= Polymorphic • Polymorphic Ventricular Tachycardia (Torsades) o Rate 200-250 o Irregular (twisting) o No P wave or PR interval o QRS wide and bizarre • Ventricular Fibrillation o Unable to determine rate o Chaotic and irregular o Lethal rhythm- CPR and Shock lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR • First Degree Heart Block o Rate- usually normal o Regular rhythm o P wave before each QRS o Prolonged PR interval >0.20 seconds o Normal QRS o Treatment not typically required • Second degree AV block- mobitz type 1- wenckeback o Atrial rate > ventricular rate o P’s march out- irregular o More p’s than qrs o QRS normal but periodically drops o Longer, longer, longer, drop o Treat only if symptomatic lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR • Perform hand exercises to promote fistula maturation • Bucks' traction = Skin traction o Never allow weights to be on floor o Can be temporarily removed with provider approval in order to complete nursing care o Generally, though, do not ever remove traction • AKI o Patho ▪ Rapid and progressive azotemia (loss of clearance of waste products) ▪ Accumulation of nitrogenous waste ▪ Oliguria likely to be present o Causes: ▪ Prerenal • Most common cause • Hypovolemia • Decreased CO • Decreased PCR • Vascular obstruction • RAAS will attempt to correct- this leads to higher BUN: creat ration and low urinary output and kidneys cannot conserve sodium leading to intrarenal damage ▪ Intrarenal • Direct damage to parenchymal tissues • Reduced nephron functioning • Prolonged ischemia • Nephrotoxins o Hemoglobin or myglobin o Aminoglycosides o Contrast dye • Acute glomerulonephritis and acute tubular necrosis are examples ▪ Postrenal • Mechanical obstruction of lower urinary tract lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR o Phases: • BPH • Prostate cancer • Calculi • Trauma • Tumors ▪ Initiating • Beginning phase that lasts until s/s appear • Hours to days • 25% decrease in circulation to kidneys is typical cause • Vasoconstriction happens • Water and sodium retention happens • Decrease in output • High spec grav and low urine sodium THE EARLY SIGNS ▪ Oliguric Phase • Urine output below 400mL daily • Urine with a fixed spec grav between 1.007 and 1.01 and high sodium concentration (in urine) indicates intrarenal damage • 50% of pts do not show oliguria • Increased BUN and creatinine • Electrolytes abnormal acidosis • Fluid overload • Can last 14 days or longer • Longer the oliguric phase is poorer prognosis • May give dialysis in this stage ▪ Diuretic Phase • Happens when cause of AKI has been resolved • Urine output can be 1-3L/ day • Can become dehydrated • Monitor electrolytes • 1-3 weeks long lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR o S/S: o Tx: • Stable acid-base, electrolytes, BUN, and creatinine towards end of this stage ▪ Recovery • GBM is restored • GFR increases to 70-80% of normal • Several months- 1 year ▪ Fluid volume overload • JVD • Edema • Pulmonary edema • SOB • Heart failure ▪ Electrolyte imbalances • Increased K • Increased phosphorus • BUN/Creatinine increased • Decreased calcium • Decreased sodium • Decreased pH • Metabolic acidosis ▪ Confusion ▪ Lethargy ▪ Seizures/ coma r/t electrolyte imbalances ▪ Maintain fluid volume ▪ Strict I&Os ▪ Diuretics (loop. Or osmotic) ▪ Nutrition: • Provide calories but keep restrictions in place • Catabolism will happen if there are not adequate calories • Carbs, fat and protein necessary lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR ▪ The blood glucose will be very high ▪ Enough insulin to prevent ketoacidosis ▪ Not enough insulin to prevent hyperglycemia ▪ Can be >600 ▪ SLOW ONSET ▪ DEHYDRATION ▪ Leads to osmotic diuresis ▪ Dehydration can be bad ▪ Electrolyte imbalances can be severe ▪ “Global” neurological defects ▪ Usually in older patients with DM 2 ▪ More mortality (10-20%) ▪ Most common in pts with illness ▪ Usually caused by illness ▪ Hard to differentiate from illness o S/S: ▪ ▪ Hyperglycemia (>600mg/ dcL) ▪ DM type II • Beta cells are still producing some insulin- enough to prevent fat breakdown • Can happen to someone who doesn't know they have DM II ▪ Hyperosmolality (bc of hyperglycemia) ▪ Dehydration ▪ NO significant ketoacidosis ▪ Serum osmolality 320 or more ▪ PH greater than 7.4 ▪ Bicarb concentration greater than 15 ▪ Low to absent ketonuria lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR ▪ Alterations in LOC o Treatment: ▪ Rehydration AGGRESSIVE • Can lead to hypovolemic shock ▪ Airway management ▪ IV insulin may be needed or fluids might work o Nursing: ▪ Monitor ▪ Take vitals ▪ Maintain fluid balance ▪ Maintain electrolyte balance ▪ REHYDRATION is focus of treatment ▪ POTASSIUM must be checked and stabilized to at least 3.3 before giving insulin • Hypoxia o Lack of oxygen perfusion to the tissues leading to tissue function decline and eventual tissue death • Liability o Idk what this means • Organ donation o OPO manages care o Report imminent death within 1 hour to OPO o Your role is to link the hospital to the OPO o May provide only opportunity for patients to have enhanced quality of life o Preferred and only treatment for end stage organ disease o Follow organ policies o Patients must have continuous hemodynamic monitor and support during declaration of brain death o Must ensure oxygenation and perfusion maintained o Electrolyte and acid base balance must be maintained lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR o Collaboration and communication with OPO o Following family’s authorization o OPO assume care of donor o Nurse and OPO protect rights of patient o After declaration- OPO is usually called before patient has died ▪ Patient is notified ▪ OPO checks donor registry ▪ Informs family how it will proceed ▪ If pt has not decided family will be asked ▪ After authorization OPO takes over care of OPO and medical management ▪ Correct deficiencies and preserve ▪ Nursing care shifts from cerebral protective strategies ▪ Attitudes and care of families can impact outcome of donation ▪ All pts meeting imminent death criteria must be referred within 1 hour ▪ All cardiac deaths must be referred regardless of age etc. ▪ Nurse calls OPO and gives all of info ▪ Categories: • Brain dead o Donor is declared dead by neurological death (doll’s eyes) • Donation after cardiac death • Living related donor o Individual related to pt • Living unrelated donor o Direct or non-direct • Living donor paired donor o Allocated paired kidney exchange o Two pairs of living kidney donors who do not have matching blood types- trade donors ON EXAM ▪ Graft rejection • Transplanted tissue is recognized as nonself lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR • Stroke o Pathophysiology: ▪ Ischemic o Decreased lung compliance o Agitation o Coughing o Gagging o Bronchospasm o S/S: o Tx: • There is a blockage in the cerebral blood flow leading to inadequate perfusion of the brain and death of tissue ▪ Hemorrhagic • There is bleeding in the brain that leads to inadequate perfusion of tissues and death of tissues ▪ One sided weakness ▪ Slurred speech ▪ Unilateral weakness ▪ Hemianopia: • One sided vision loss meaning the pt should scan the room to ensure safety when ambulating ▪ Aphasia ▪ Facial droop ▪ BE FAST • Balance • Eyes • Facial • Arm • Speech • Time ▪ CT Scan fast lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR o Dx: ▪ STAY WITH PT ▪ TPA- alteplase • Given IV bolus • 10% over first 1-2min • Hang remaining 90% for an hour • KNOW ELIGIBILITY FOR TPA o Usually given within 3 hours of sx onset o Usually, Dr. Is going to ask questions on hx of sx etc. • Risk for TPA o Bleeding ▪ Can pt be hypotensive • NO- they need blood flow ▪ CT scan Burns o Complications ▪ Permanent brain damage leading to cognitive decline ▪ Aphasia ▪ Dysphagia o Nursing: ▪ Act quickly when s/s of stroke are present • Burn Depth o Superficial ▪ Tissues • Minimal damage to epidermis ▪ Wound • Dry • No blisters • Pink/red • Blanches easily lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR ▪ Pain • Hypersensitive ▪ Healing • 3-7 days without scarring o Superficial Partial Thickness ▪ Tissues • Entire epidermis with minimal damage to dermis ▪ Wound • Blisters may be open, closed, or weeping • Pink or red • Mild edema • Blanches easily ▪ Pain • Hypersensitive ▪ Healing • 7-14 days without scarring o Deep Partial Thickness ▪ Tissues • Entire epidermis and deeper layers of the dermis ▪ Wound • Blisters may be closed or open • Waxy appearance • Cherry red, mottled, or pale in the center • Edema • No blanching ▪ Pain • Hypersensitive around wound edges • May be sensitive to pressure only in center ▪ Healing • May take 3-6 weeks to heal with some scarring • May have to be surgically excised o Full Thickness lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR • Might have change in voice • Anxiety/confusion • Singed nasal hairs • Soot in sputum • Escharotomies and Fasciotomies o Circumferential burns to extremities are at risk for developing compartment syndrome o Escharotomy ▪ Surgical incision through eschar ▪ Chest wall escharotomies are considered medical emergencies o Fasciotomy ▪ Performed when burn extends into the muscle ▪ Extends through subcutaneous fat and muscle fascia allowing for expansion of muscle compartment ▪ Most common in patients with electrical burns who have developed compartment syndrome • Review Question o Burn patient has reduced urine output during fluid resuscitation, what is an appropriate nursing action? ▪ Normal response ▪ DO NOT give diuretic o What type of data will you collect while assessing a burn patient? ▪ Severity ▪ Depth ▪ V/S- hypothermia is a significant concern ▪ Fluid status and electrolytes ▪ % of body surface area Fluid Resuscitation and medications • Fluid resuscitation o Crucial for patients who have TBSA burns of 20% or greater o Need two large bore peripheral IV catheters in unburned skin o IO lines are also acceptable o Fluid Formula lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR ▪ 2-4ml of fluid/kg of body weight x TBSA • Give ½ during 1st 8 hours • Give 2nd ½ over the next 16 hours o Need indwelling catheter to monitor I/O • Medications o Pain medications o Sedatives o Anticoagulants o Antibiotics if indicated- typically not given prophylactically Trauma • Review Question o What is the first primary assessment of a trauma patient? ▪ LOC/GCS HIT • Appears to be an autoimmune response to exogenous heparin • Body produces antibodies against the heparin • Occurs 5-14 days after the administration of heparin • The antibodies initiate a response leading to the production of new blood clots o These blood clots lead to a fall in platelets (thrombocytopenia) as they are being used to form these thrombi • Stopping Heparin is first step in treatment o Must follow up with additional anticoagulant due to clotting being present ▪ Argatroban, danaparoid, and leperudin are approved ▪ DO NOT USE WARFARIN (apparently causes gangrene) • Review Question o Medication for HIT? ▪ Argatroban (previous test question) DIC • Intravascular coagulation secondary to severe trauma or severe tissue injury • High mortality rate associated with DIC due to multi-organ system dysfunction and hemorrhage • Manifestations o Cyanotic nail beds lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR o Easily bruised o Petechiae o Bleeding from nose/gums o GI bleeds o Hematuria o Literally blood everywhere • Treatment o Resolution of underlying condition ▪ (Sepsis-antibiotics) ▪ Snake-bite-antivenom o Glucocorticoids o Replace platelets o Heparin due to micro clots • Review Questions o What are some clinical manifestations of DIC? ▪ Petechiae ▪ Hematuria o What is a treatment option for DIC? ▪ May need to give platelets Kidney transplantation • Tissue must be matched with a donor o Donor may be ▪ Living ▪ Non-heart beating ▪ Cadaver • Indication for Transplant o End stage renal disease (not a cure, but improves quality of life) ▪ Clinical Manifestations of Kidney Disease • Anorexia, fatigue • Numbness, tingling in extremities • Shortness of breath lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR Shock ▪ Blood products ▪ Need periods of rest (previous test question) o How does MODS happen? ▪ Sepsis is the most common cause ▪ Progressive process of organs not being perfused • What is it? o Occurs when the cardiovascular system is unable to supply adequate amounts of oxygen to tissues to meet basic metabolic demands • Classifications o Hypovolemic ▪ Occurs with rapid fluid loss resulting in inadequate circulatory volume ▪ Most commonly secondary to blood loss from penetrating injury, blunt trauma, or severe GI bleeds ▪ Could also be caused by nausea, vomiting, or burns ▪ Third spacing ▪ Clinical Manifestations • Early Stages: Elevated heart rate, restless, confused, decreased urine output, skin becomes cool, pale, and clammy. Weak pulses with sluggish capillary refill time. Hyperventilation leads to initial respiratory alkalosis. Decreased bowel sounds and hyperglycemia • Late signs: Lethargy, hypotension, metabolic and respiratory acidosis, anuria, cold/cyanotic skin, weak or absent pulses and dysrhythmias. ▪ Treatment • Rapid fluid resuscitation is the mainstay treatment ▪ Nursing Management • Assess vitals • Daily weights • Urine output • Capillary refill ▪ Assessment Priority • Neuro status • Vital signs • Daily weight lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR o Cardiogenic • Urine output • Capillary refill ▪ The heart is not pumping adequately resulting in decreased cardiac output ▪ Usually result of an MI ▪ Independent of fluid volume status ▪ Clinical Manifestations • Like acute MI • Chest pain, diaphoresis, N/V • Cool, pale, moist skin • Hypotension • Altered LOC o Distributive ▪ Sepsis, anaphylaxis, or neurogenic shock ▪ Each of these results in poor vascular tone and vasodilation which leads to increased vascular capacity and venous pooling ▪ Venous pooling causes a decrease in venous return to the right atrium ▪ Clinical Manifestations • Anaphylactic shock: o How does it happen: Repeated exposure, Immunoglobulin E antibodies o S/S: SOB, tachypnea, wheezing, stridor, cyanosis, and confusion, cool, pale, clammy skin o Treatment: Epinephrine o Obstructive ▪ Mechanical barrier to ventricular filling or emptying ▪ Cardiac tamponade/tension pneumothorax ▪ Clinical Manifestations • Stages of Shock o Initial Stage ▪ Clinical Manifestations • Subtle, if any ▪ Marked by hypoxia due to decreased DO2 to the cells lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR ▪ Clinical manifestations are subtle, but damage may be occurring ▪ There will be decreased cardiac output o Compensatory Stage ▪ Clinical Manifestations • Restlessness, confusion, tachycardia, tachypnea, respiratory alkalosis, oliguria, hyperglycemia, decreased bowel sounds, weak pulses, cool/moist skin ▪ Characterized by compensatory mechanisms to maintain adequate volume, cardiac output, and blood flow to the tissues ▪ Includes Neural, endocrine, and chemical compensations ▪ Neural Compensation • Detection of hypotension by baroreceptors which stimulates the sympathetic nervous system which releases catecholamines (epinephrine and norepinephrine) from the adrenal medulla • The release of epinephrine and norepinephrine results in vasoconstriction, increased cardiac output, and redistribution of blood away from kidneys, GI tract, and skin to vital organs ▪ Endocrine Compensation • Hormones that exert control over blood pressure include epinephrine and norepinephrine, ADH, angiotensin II, and aldosterone • RAAS • Glucose is also released for energy ▪ Chemical Compensation • Produced through a reaction of chemoreceptors in the aorta and carotid arteries that are stimulated by low oxygen levels • Tachypnea occurs to increase circulating oxygen o Progressive Stage ▪ Clinical Manifestations • Lethargy, coma, hypotension, dysrhythmias, anuria, absent bowel sounds, cold extremities, weak or absent pulses ▪ Marked by the failure of compensatory mechanisms ▪ Extensive shunting of blood to vital organs ▪ Profound hypoperfusion will occur without treatment which can lead to metabolic acidosis, electrolyte imbalances, and respiratory acidosis o Refractory Stage ▪ Clinical Manifestations lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR • Gradual improvement in signs and symptoms • Clinical Manifestations o Symmetrical ascending motor weakness and paralysis that starts in the feet and extends to the trunk and arms o May complain of paresthesia and pain that involves the shoulders, buttocks, and upper legs o First few days: Weakness, diminished or absent deep tendon reflexes ▪ Areflexia is a key finding in GBS o Cranial nerve involvement ▪ Facial nerve most affected ▪ Cranial nerves IX, X, XI, and XII might be affected and cause dysphagia o Autonomic dysfunction ▪ Cardiac dysrhythmias ▪ Paroxysmal hypotension ▪ Paralytic ileus ▪ Urinary retention ▪ SIADH o Respiratory Impairment ▪ Respiratory failure o LOC and cognition remain intact • Management o Diagnosis ▪ Diagnostic criteria • Progressive weakness of two or more limbs caused by neuropathy, areflexia, and history of recent illness ▪ Lubar puncture will show elevated proteins ▪ Electromyography • Reveal slowed nerve conduction velocity • Patient will have to flex muscles and avoid applying lotions o Medications ▪ IVIG • Can shorten length of recovery by 50% ▪ Plasmapheresis lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR o Diet • Recommended for Non ambulatory adults who start treatment within 4 weeks of onset of neuropathic symptoms • Recommended for ambulatory adults who start treatment within 2 weeks ▪ Carbamazepine or gabapentin may be given for neuropathy ▪ Should be evaluated for dysphagia and risk for aspiration ▪ Enteral feeding may be initiated • Complications o Respiratory status is monitored ▪ Breath sounds ▪ Forced vital capacity ▪ Ventilation is compromised by loss of motor innervation to the skeletal muscles of respiration o Complications of immobility ▪ Should be given subq heparin ▪ Antiembolism stockings ▪ At risk of pressure injuries ▪ Patients may sweat a lot and be at risk of shearing • Review Question o Apparently, one is super obvious ▪ I'm thinking it'll be respiratory related...just a hunch o What should these patients get/not get? ▪ Patients should get • IVIG • Plasmapheresis • Carbamazepine/gabapentin • Potential need for mechanical ventilation ▪ Patients should not get • Certain vaccines may be contraindicated Increased Intracranial Pressure • Pathophysiology o Cerebral herniation classified by region is displaced o Cushing's triad is a sign of herniation and a late sign of increased ICP o Another late sign of increased ICP is unilateral, fixed and dilated pupil • Clinical Manifestations o Early Sign: decreased LOC lOMoARcPSD|16870840 NUR 445 Collaborative Final EXAM Study Guide Acute & Chronic Health Disruptions In Adults III  2024 EXAM PREDICTOR ▪ Alertness and awareness o Nausea and Vomiting, headache o Babinski Reflex in indicative of cerebral herniation ▪ Test by stroking outer aspect of foot from heel to toe ▪ Toes fanning up is a positive sign and a clinical manifestation of cerebral herniation o Cushing's Triad • Intracranial Pressure Monitoring o Patients with a traumatic brain injury or a Glasgow Coma Scale score of 8 or below should have an ICP monitor in place o Normal ICP is between 0-15 mm HG o The Gold standard monitor is the Intraventricular Catheter ▪ It is used for monitoring ICP and draining ▪ Placed in one of the lateral ventricles in the brain • Management o Diagnosis ▪ MRI • Patients should remove all metal prior to MRI. Patient should inform staff of any implanted devices • Patient shouldn’t eat (Previous test question) ▪ Labs • Serum osmolality o 275-296 • Sodium • ABGs o Medications ▪ Mannitol • Pulls fluid from interstitial spaces into vascular system • Eliminates fluid though kidneys ▪ Hypertonic solution • Does not have diuretic effect • If given too fast or sodium levels rise too high in a short amount of time could lead to osmotic demyelination syndrome o Physical Interventions