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RN ADULT MEDICAL SURGICAL NURSING I
RN Adult Medical Surgical NursingREVIEW MODULE EDITION 11.0
ContributorsHoney C. Holman, MSN, RN
Debborah Williams, MSN, RN
Sheryl Sommer, PhD, RN, CNE
Janean Johnson, MSN, RN, CNE
Brenda S. Ball, MEd, BSN, RN
LaKeisha Wheless, MSN, RN
Peggy Leehy, MSN, RN
Terri Lemon, DNP, MSN, RN
ConsultantsGreta Lucinda Baldwin Mason, MSN, RN
Christi Blair, DNP, RN
Tracey Bousquet, BSN, RN
Valerie S. Eschiti, PhD, RN, AHN-BC, CHTP, CTN-A
Penny Fauber, PhD, MS, BSN, RN
Sara Hoffmann, MSN, RN
Tomekia Luckett, PhD, RN
Donna Russo, RN, MSN, CCRN, CNE
Melanie P. Schrader, PhD, RN
INTELLECTUAL PROPERTY NOTICEATI Nursing is a division of Assessment Technologies Institute®, LLC.
Copyright © 2019 Assessment Technologies Institute, LLC. All rights reserved.
The reproduction of this work in any electronic, mechanical or other means, now known or hereafter
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third parties who have licensed their materials to Assessment Technologies Institute, LLC.
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II CONTENT MASTERY SERIES
IMPORTANT NOTICE TO THE READERAssessment Technologies Institute, LLC, is the publisher of this publication. The content of this publication is for
informational and educational purposes only and may be modified or updated by the publisher at any time. This
publication is not providing medical advice and is not intended to be a substitute for professional medical advice,
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Director of content review: Kristen Lawler
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RN ADULT MEDICAL SURGICAL NURSING User’s GUide III
User’s GuideWelcome to the Assessment Technologies Institute® RN Adult Medical Surgical Nursing Review Module Edition 11.0. The mission of ATI’s Content Mastery Series® Review Modules is to provide user-friendly compendiums of nursing knowledge that will:
● Help you locate important information quickly. ● Assist in your learning efforts. ● Provide exercises for applying your nursing knowledge. ● Facilitate your entry into the nursing profession as a
newly licensed nurse.
This newest edition of the Review Modules has been redesigned to optimize your learning experience. We’ve fit more content into less space and have done so in a way that will make it even easier for you to find and understand the information you need.
ORGANIZATIONThis Review Module is organized into units covering the foundations of nursing care (Unit 1), body systems and physiological processes (Units 2 to 13), and perioperative nursing care (Unit 14). Chapters within these units conform to one of three organizing principles for presenting the content.
● Nursing concepts ● Procedures ● System disorders
Nursing concepts chapters begin with an overview describing the central concept and its relevance to nursing. Subordinate themes are covered in outline form to demonstrate relationships and present the information in a clear, succinct manner.
Procedures chapters include an overview describing the procedure(s) covered in the chapter. These chapters provide nursing knowledge relevant to each procedure, including indications, nursing considerations, interpretation of findings, and complications.
System disorders chapters include an overview describing the disorder(s) and/or disease process. These chapters address assessments, including risk factors, expected findings, laboratory tests, and diagnostic procedures. Next, you will focus on patient-centered care, including nursing care, medications, therapeutic procedures, interprofessional care, and client education. Finally, you will find complications related to the disorder, along with nursing actions in response to those complications.
ACTIVE LEARNING SCENARIOS AND APPLICATION EXERCISES
Each chapter includes opportunities for you to test your knowledge and to practice applying that knowledge. Active Learning Scenario exercises pose a nursing scenario and then direct you to use an ATI Active Learning Template (included at the back of this book) to record the important knowledge a nurse should apply to the scenario. An example is then provided to which you can compare your completed Active Learning Template. The Application Exercises include NCLEX-style questions, such as multiple-choice and multiple-select items, providing you with opportunities to practice answering the kinds of questions you might expect to see on ATI assessments or the NCLEX. After the Application Exercises, an answer key is provided, along with rationales.
NCLEX® CONNECTIONSTo prepare for the NCLEX-RN, it is important to understand how the content in this Review Module is connected to the NCLEX-RN test plan. You can find information on the detailed test plan at the National Council of State Boards of Nursing’s website, www.ncsbn.org. When reviewing content in this Review Module, regularly ask yourself, “How does this content fit into the test plan, and what types of questions related to this content should I expect?”
To help you in this process, we’ve included NCLEX Connections at the beginning of each unit and with each question in the Application Exercises Answer Keys. The NCLEX Connections at the beginning of each unit point out areas of the detailed test plan that relate to the content within that unit. The NCLEX Connections attached to the Application Exercises Answer Keys demonstrate how each exercise fits within the detailed content outline.These NCLEX Connections will help you understand how the detailed content outline is organized, starting with major client needs categories and subcategories and followed by related content areas and tasks. The major client needs categories are:
● Safe and Effective Care Environment ◯ Management of Care ◯ Safety and Infection Control
● Health Promotion and Maintenance ● Psychosocial Integrity ● Physiological Integrity
◯ Basic Care and Comfort ◯ Pharmacological and Parenteral Therapies ◯ Reduction of Risk Potential ◯ Physiological Adaptation
An NCLEX Connection might, for example, alert you that content within a unit is related to:
● Reduction of Risk Potential ◯ Diagnostic Tests
■ Monitor the results of diagnostic testing and intervene as needed.
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IV User’s GUide CONTENT MASTERY SERIES
QSEN COMPETENCIESAs you use the Review Modules, you will note the integration of the Quality and Safety Education for Nurses (QSEN) competencies throughout the chapters. These competencies are integral components of the curriculum of many nursing programs in the United States and prepare you to provide safe, high-quality care as a newly licensed nurse. Icons appear to draw your attention to the six QSEN competencies.
Safety: The minimization of risk factors that could cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others.
Patient-Centered Care: The provision of caring and compassionate, culturally sensitive care that addresses clients’ physiological, psychological, sociological, spiritual, and cultural needs, preferences, and values.
Evidence-Based Practice: The use of current knowledge from research and other credible sources, on which to base clinical judgment and client care.
Informatics: The use of information technology as a communication and information-gathering tool that supports clinical decision-making and scientifically based nursing practice.
Quality Improvement: Care related and organizational processes that involve the development and implementation of a plan to improve health care services and better meet clients’ needs.
Teamwork and Collaboration: The delivery of client care in partnership with multidisciplinary members of the health care team to achieve continuity of care and positive client outcomes.
ICONSIcons are used throughout the Review Module to draw your attention to particular areas. Keep an eye out for these icons.
This icon is used for NCLEX Connections.
This icon indicates gerontological considerations, or knowledge specific to the care of older adult clients.
This icon is used for content related to safety and is a QSEN competency. When you see this icon, take note of safety concerns or steps that nurses can take to ensure client safety and a safe environment.
This icon is a QSEN competency that indicates the importance of a holistic approach to providing care.
This icon, a QSEN competency, points out the integration of research into clinical practice.
This icon is a QSEN competency and highlights the use of information technology to support nursing practice.
This icon is used to focus on the QSEN competency of integrating planning processes to meet clients’ needs.
This icon highlights the QSEN competency of care delivery using an interprofessional approach.
This icon appears at the top-right of pages and indicates availability of an online media supplement, such as a graphic, animation, or video. If you have an electronic copy of the Review Module, this icon will appear alongside clickable links to media supplements. If you have a hard copy version of the Review Module, visit www.atitesting.com for details on how to access these features.
FEEDBACKATI welcomes feedback regarding this Review Module. Please provide comments to [email protected].
As needed updates to the Review Modules are identified, changes to the text are made for subsequent printings of the book and for subsequent releases of the electronic version. For the printed books, print runs are based on when existing stock is depleted. For the electronic versions, a number of factors influence the update schedule. As such, ATI encourages faculty and students to refer to the Review Module addendums for information on what updates have been made. These addendums, which are available in the Help/FAQs on the student site and the Resources/eBooks & Active Learning on the faculty site, are updated regularly and always include the most current information on updates to the Review Modules.
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RN ADULT MEDICAL SURGICAL NURSING TABLe OF CONTeNTs V
Table of Contents
NCLEX® Connections 1
UNIT 1 Foundations of Nursing Care for Adult Clients 3
CHAPTER 1 Health, Wellness, and Illness 3
CHAPTER 2 Emergency Nursing Principles and Management 7
NCLEX® Connections 15
UNIT 2 Neurologic Disorders 17SECTION: Diagnostic and Therapeutic Procedures 17
CHAPTER 3 Neurologic Diagnostic Procedures 17
CHAPTER 4 Pain Management 25
SECTION: Central Nervous System Disorders 31
CHAPTER 5 Meningitis 31
CHAPTER 6 Seizures and Epilepsy 35
CHAPTER 7 Parkinson’s Disease 41
CHAPTER 8 Alzheimer’s Disease 47
CHAPTER 9 Brain Tumors 53
CHAPTER 10 Multiple Sclerosis 59
CHAPTER 11 Headaches 63
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VI TABLe OF CONTeNTs CONTENT MASTERY SERIES
SECTION: Sensory Disorders 67
CHAPTER 12 Disorders of the Eye 67
CHAPTER 13 Middle and Inner Ear Disorders 73
SECTION: Neurologic Emergencies 81
CHAPTER 14 Head Injury 81
CHAPTER 15 Stroke 87
CHAPTER 16 Spinal Cord Injury 95
NCLEX® Connections 103
UNIT 3 Respiratory Disorders 105SECTION: Diagnostic and Therapeutic Procedures 105
CHAPTER 17 Respiratory Diagnostic Procedures 105
CHAPTER 18 Chest Tube Insertion and Monitoring 111
CHAPTER 19 Respiratory Management and Mechanical Ventilation 115
SECTION: Respiratory System Disorders 125
CHAPTER 20 Acute Respiratory Disorders 125
CHAPTER 21 Asthma 133
CHAPTER 22 Chronic Obstructive Pulmonary Disease 137
CHAPTER 23 Tuberculosis 143
SECTION: Respiratory Emergencies 149
CHAPTER 24 Pulmonary Embolism 149
CHAPTER 25 Pneumothorax, Hemothorax, and Flail Chest 155
CHAPTER 26 Respiratory Failure 161
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RN ADULT MEDICAL SURGICAL NURSING TABLe OF CONTeNTs VII
NCLEX® Connections 167
UNIT 4 Cardiovascular Disorders 169SECTION: Diagnostic and Therapeutic Procedures 169
CHAPTER 27 Cardiovascular Diagnostic and Therapeutic Procedures 169
CHAPTER 28 Electrocardiography and Dysrhythmia Monitoring 179
CHAPTER 29 Pacemakers and Implantable Cardioverter/Defibrillators 185
CHAPTER 30 Invasive Cardiovascular Procedures 191
SECTION: Cardiac Disorders 199
CHAPTER 31 Angina and Myocardial Infarction 199
CHAPTER 32 Heart Failure and Pulmonary Edema 205
CHAPTER 33 Valvular Heart Disease 213
CHAPTER 34 Inflammatory Disorders 219
SECTION: Vascular Disorders 223
CHAPTER 35 Peripheral Vascular Diseases 223
CHAPTER 36 Hypertension 233
CHAPTER 37 Hemodynamic Shock 239
CHAPTER 38 Aneurysms 247
NCLEX® Connections 253
UNIT 5 Hematologic Disorders 255SECTION: Diagnostic and Therapeutic Procedures 255
CHAPTER 39 Hematologic Diagnostic Procedures 255
CHAPTER 40 Blood and Blood Product Transfusions 259
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VIII TABLe OF CONTeNTs CONTENT MASTERY SERIES
SECTION: Hematologic Disorders 265
CHAPTER 41 Anemias 265
CHAPTER 42 Coagulation Disorders 271
NCLEX® Connections 275
UNIT 6 Fluid/Electrolyte/Acid‑Base Imbalances 277CHAPTER 43 Fluid Imbalances 277
CHAPTER 44 Electrolyte Imbalances 283
Sodium imbalances 283
Potassium imbalances 285
Other electrolyte imbalances 288
CHAPTER 45 Acid‑Base Imbalances 293
NCLEX® Connections 299
UNIT 7 Gastrointestinal Disorders 301SECTION: Diagnostic and Therapeutic Procedures 301
CHAPTER 46 Gastrointestinal Diagnostic Procedures 301
CHAPTER 47 Gastrointestinal Therapeutic Procedures 309
SECTION: Upper Gastrointestinal Disorders 319
CHAPTER 48 Esophageal Disorders 319
CHAPTER 49 Peptic Ulcer Disease 327
CHAPTER 50 Acute and Chronic Gastritis 333
SECTION: Lower Gastrointestinal Disorders 339
CHAPTER 51 Noninflammatory Bowel Disorders 339
CHAPTER 52 Inflammatory Bowel Disease 347
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RN ADULT MEDICAL SURGICAL NURSING TABLe OF CONTeNTs IX
SECTION: Gallbladder and Pancreas Disorders 355
CHAPTER 53 Cholecystitis and Cholelithiasis 355
CHAPTER 54 Pancreatitis 359
SECTION: Liver Disorders 365
CHAPTER 55 Hepatitis and Cirrhosis 365
NCLEX® Connections 373
UNIT 8 Renal Disorders 375SECTION: Diagnostic and Therapeutic Procedures 375
CHAPTER 56 Renal Diagnostic Procedures 375
CHAPTER 57 Hemodialysis and Peritoneal Dialysis 379
CHAPTER 58 Kidney Transplant 385
SECTION: Renal System Disorders 391
CHAPTER 59 Polycystic Kidney Disease, Acute Kidney Injury, and Chronic Kidney Disease 391
CHAPTER 60 Infections of the Renal and Urinary System 399
CHAPTER 61 Renal Calculi 407
NCLEX® Connections 413
UNIT 9 Reproductive Disorders 415SECTION: Female Reproductive Disorders 415
CHAPTER 62 Diagnostic and Therapeutic Procedures for Female Reproductive Disorders 415
CHAPTER 63 Female Physiologic Processes 423
CHAPTER 64 Disorders of Female Reproductive Tissue 429
SECTION: Male Reproductive Disorders 435
CHAPTER 65 Diagnostic Procedures for Male Reproductive Disorders 435
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X TABLe OF CONTeNTs CONTENT MASTERY SERIES
CHAPTER 66 Benign Prostatic Hyperplasia, Erectile Dysfunction, and Prostatitis 439
NCLEX® Connections 445
UNIT 10 Musculoskeletal Disorders 447SECTION: Diagnostic and Therapeutic Procedures 447
CHAPTER 67 Musculoskeletal Diagnostic Procedures 447
CHAPTER 68 Arthroplasty 453
CHAPTER 69 Amputations 459
SECTION: Musculoskeletal Disorders 463
CHAPTER 70 Osteoporosis 463
CHAPTER 71 Musculoskeletal Trauma 469
CHAPTER 72 Osteoarthritis and Low‑Back Pain 479
NCLEX® Connections 487
UNIT 11 Integumentary Disorders 489SECTION: Diagnostic and Therapeutic Procedures 489
CHAPTER 73 Integumentary Diagnostic Procedures 489
SECTION: Integumentary Disorders 493
CHAPTER 74 Skin Disorders 493
CHAPTER 75 Burns 499
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RN ADULT MEDICAL SURGICAL NURSING TABLe OF CONTeNTs XI
NCLEX® Connections 509
UNIT 12 Endocrine Disorders 511SECTION: Diagnostic and Therapeutic Procedures 511
CHAPTER 76 Endocrine Diagnostic Procedures 511
SECTION: Pituitary Disorders 519
CHAPTER 77 Pituitary Disorders 519
SECTION: Thyroid Disorders 525
CHAPTER 78 Hyperthyroidism 525
CHAPTER 79 Hypothyroidism 531
SECTION: Adrenal Disorders 535
CHAPTER 80 Cushing’s Disease/Syndrome 535
CHAPTER 81 Addison’s Disease and Acute Adrenal Insufficiency (Addisonian Crisis) 541
SECTION: Diabetes Mellitus 545
CHAPTER 82 Diabetes Mellitus Management 545
CHAPTER 83 Complications of Diabetes Mellitus 555
NCLEX® Connections 559
UNIT 13 Immune System and Connective Tissue Disorders 561SECTION: Diagnostic and Therapeutic Procedures 561
CHAPTER 84 Immune and Infectious Disorders Diagnostic Procedures 561
CHAPTER 85 Immunizations 565
SECTION: Immune Disorders 571
CHAPTER 86 HIV/AIDS 571
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XII TABLe OF CONTeNTs CONTENT MASTERY SERIES
SECTION: Connective Tissue Disorders 577
CHAPTER 87 Lupus Erythematosus, Gout, and Fibromyalgia 577
CHAPTER 88 Rheumatoid Arthritis 585
SECTION: Cancer‑Related Disorders 591
CHAPTER 89 General Principles of Cancer 591
CHAPTER 90 Cancer Screening and Diagnostic Procedures 597
CHAPTER 91 Cancer Treatment Options 601
CHAPTER 92 Cancer Disorders 611
CHAPTER 93 Pain Management for Clients Who Have Cancer 645
NCLEX® Connections 651
UNIT 14 Nursing Care of Perioperative Clients 653CHAPTER 94 Anesthesia and Moderate Sedation 653
Anesthesia 653
Moderate sedation 656
CHAPTER 95 Preoperative Nursing Care 659
CHAPTER 96 Postoperative Nursing Care 665
Active Learning Templates A1Basic Concept A1
Diagnostic Procedure A3
Growth and Development A5
Medication A7
Nursing Skill A9
System Disorder A11
Therapeutic Procedure A13
Concept Analysis A15
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RN ADULT MEDICAL SURGICAL NURSING NCLeX® CONNeCTiONs 1
NCLEX® Connections
When reviewing the following chapters, keep in mind the relevant topics and tasks of the NCLEX outline, in particular:
Health Promotion and MaintenanceHEALTH PROMOTION/DISEASE PREVENTIONIdentify risk factors for disease/illness.
Educate the client on actions to promote/maintain health and prevent disease.
HEALTH SCREENING: Apply knowledge of pathophysiology to health screening.
Physiological AdaptationHEMODYNAMICS: Intervene to improve the client’s cardiovascular status.
ILLNESS MANAGEMENT: Educate client about managing illness.
MEDICAL EMERGENCIES: Apply knowledge of pathophysiology when caring for a client experiencing a medical emergency.
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2 NCLeX® CONNeCTiONs CONTENT MASTERY SERIES
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 1 HeALTH, WeLLNess, ANd iLLNess 3
UNIT 1 FOUNDATIONS OF NURSING CARE FOR ADULT CLIENTS
CHAPTER 1 Health, Wellness, and Illness
Health and wellness combine to form a state of optimal physical functioning and a feeling of emotional and social contentment. Wellness involves the ability to adapt emotionally and physically to a changing state of health and environment.
illness is an altered level of functioning in response to a disease process. disease is a condition that results in the physiological alteration in the composition of the body.
Nurses must understand the variables affecting health, wellness, and illness, and how they relate to clients’ individual perceptions of health needs.
Health and wellnessThe level of health and wellness is unique to each individual and relative to the individual’s usual state of functioning. For example, a person who has rheumatoid arthritis, a strong support system, and positive outlook might consider himself healthy while functioning at an optimal level with minimal pain.
VARIABLES ● Modifiable: Can be changed, such as smoking,
nutrition, access to health education, sexual practices, and exercise
● Non-modifiable: Cannot be changed, such as sex, age, developmental level, and genetic traits
ASPECTS OF HEALTH AND WELLNESS ● Physical: Able to perform activities of daily living ● Emotional: Adapts to stress; expresses and
identifies emotions ● Social: Interacts successfully with others ● Intellectual: Effectively learns and disseminates
information ● Spiritual: Adopts a belief that provides meaning to life ● Occupational: Balances occupational activities with
leisure time ● Environmental: Creates measures to improve standards
of living and quality of life
ENVIRONMENT ● A client’s state of health and wellness is constantly
changing and adapting to a continually fluctuating external and internal environment.
● THE EXTERNAL ENVIRONMENT ◯ Social: Crime vs. safety, poverty vs. prosperity, peace vs. social unrest, and presence vs. absence of support from social networks
◯ Physical: Access to health care, sanitation, availability of clean water, and geographic location
● THE INTERNAL ENVIRONMENT includes cumulative life experiences, cultural and spiritual beliefs, age, developmental stage, gender, emotional factors, and perception of physical functioning.
DESIRED OUTCOMES ● Desired outcomes are to obtain and maintain optimal
state of wellness and function through access to and use of health promotion, wellness, and illness prevention strategies.
● Health and wellness can be achieved through health education and positive action (stress management, smoking cessation, weight loss, immunizations, seeking health care).
ILLNESS‑WELLNESS CONTINUUMThe Illness-Wellness Continuum is an assessment tool used to measure the level of wellness to premature death.
● It can be useful as an assessment guide or tool to set goals and find ways to improve a client’s state of health or to have the client return to a previous state of health, which can include an illness within optimal wellness. The health care professional can assist the client to see where he is at on the continuum and seek ways to move toward optimal wellness.
● At the center of the continuum is the client’s normal state of health.
● The range of wellness to illness runs from optimal wellness to severe illness.
● The degree of wellness is relative to the usual state of wellness for a client and is achieved through awareness, education, and personal growth.
Illness ● Illness is the impairment of a client’s physical, social,
emotional, spiritual, developmental, or intellectual functioning.
● Illness encompasses the effects of a disease on a client. However, illness and disease are not synonymous.
Response to illness can be influenced by: ● Degree of physical changes as a result of a
disease process. ● Perceptions by self and others of the illness, which can
be influenced by various reliable and unreliable sources of information (friends, magazines, TV, internet).
● Cultural values and beliefs. ● Denial or fear of illness. ● Social demands, time constraints, economic resources,
and health care access.
CHAPTER 1
4 CHAPTER 1 HeALTH, WeLLNess, ANd iLLNess CONTENT MASTERY SERIES
HEALTH PROMOTION AND DISEASE PREVENTION
Use health education and awareness to reduce risk factors and promote health care.
HeALTH/WeLLNess AssessMeNT ● Physical assessment ● Evaluating health perceptions ● Identifying risks to health/wellness ● Identifying access to health care
Identifying obstacles to compliance and adherence: ● Perceptions of illness: awareness of the severity of
the illness ● Confidence in the provider ● Belief in the prescribed therapy
◯ A client who has had a negative experience with the health care system might not trust the provider and might not follow the advice or comply with the treatment prescribed.
◯ Cultural or religious beliefs might not align with the prescribed treatment.
● Availability of support systems ● Family role and function: One family member might be
the family caregiver but neglect caring for herself. ● Financial restrictions that can lead to prioritized
health care ◯ Prescription medication costs ◯ A parent might seek medical care for children, but not for herself
NUrsiNG CAreEvaluate the health needs of a client and create strategies to meet those needs.
iNTerVeNTiONs ● Provide resources to strengthen coping abilities. ● Identify and encourage use of support systems during
times of illness and stress. ● Identify obstacles to health and wellness and create
strategies to reduce these obstacles. ● Identify ways to reduce health risks and
improve compliance. ● Develop health education methods to improve health
awareness and reduce health risks.
Application Exercises
1. A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus and reports difficulty following the diet and remembering to take the prescribed medication. Which of the following actions should the nurse take to promote client compliance? (select all that apply.)
A. Ask the dietitian to assist with meal planning.
B. Contact the client’s support system.
C. Assess for age‑related cognitive awareness.
d. encourage the use of a daily medication dispenser.
e. Provide educational materials for home use.
2. A nurse in a health care clinic is evaluating the level of wellness for clients using the illness‑wellness continuum tool. The nurse should identify which of the following clients as being at the center of the continuum?
A. A college student who has influenza
B. An older adult who has a new diagnosis of type 2 diabetes mellitus
C. A new mother who has a urinary tract infection
d. A young male client who has a long history of well‑controlled rheumatoid arthritis
3. A nurse is evaluating clients at a health fair for modifiable variables affecting health and wellness. The nurse should identify which of the following variables as modifiable? (select all that apply.)
A. smoking on social occasions
B. BMi of 28
C. Alopecia
d. Trisomy 21
e. History of reflux
4. A nurse is caring for a client who was just informed of a new diagnosis of breast cancer. The nurse evaluates the client’s response. Which of the following statements by the client reflects a lack of understanding of an illness perspective?
A. “i have no family history of breast cancer.”
B. “i need a second opinion. There is no lump.”
C. “i am glad we live in the city near several large hospitals.”
d. “i will schedule surgery next week, over the holidays.”
Active Learning Scenario
A nurse in a clinic is caring for a client who continues to smoke despite numerous attempts to quit and has a family history of cardiovascular disease. What nursing interventions should the nurse use to meet the health needs of this client? Use the ATi Active Learning Template: Basic Concept to complete this item.
RELATED CONTENT: include one statement identifying the goal.
UNDERLYING PRINCIPLES: include one statement regarding health promotion and disease prevention.
NURSING INTERVENTIONS: include a minimum of four.
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 1 HeALTH, WeLLNess, ANd iLLNess 5
Application Exercises Key
1. A. CORRECT: The nurse provides resources to strengthen coping abilities by asking the dietitian to assist the client with meal planning. This will improve client compliance.
B. CORRECT: With the client’s consent, the nurse can contact members of the client’s support system and encourage the client to use this support during times of illness and stress to improve compliance.
C. Assessing the client for age‑related cognitive awareness is important but it is not an appropriate intervention that enhances the client’s compliance.
d. CORRECT: The nurse encourages the use of a daily medication dispenser to reduce health risks and improve medication compliance by the client.
e. CORRECT: The nurse provides educational materials to the client to improve health awareness and reduce health risks after discharge.
NCLEX® Connection: Physiological Adaptation, Alterations in Body Systems
2. A. The client who has influenza is measured on the continuum by the level of health to illness in comparison to the norm for the client.
B. The client who is newly diagnosed with type 2 diabetes mellitus is measured by the level of health to illness in comparison to the norm for the client.
C. The client who has a urinary tract infection is measured on the continuum by the level of health to illness in comparison to the norm for the client.
d. CORRECT: The client who has well‑controlled rheumatoid arthritis is measured at the center of the continuum, which is the client’s normal state of health.
NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions
3. A. CORRECT: The nurse identifies smoking as a modifiable variable that a client can change. The nurse should provide the client with educational materials and information on smoking cessation.
B. CORRECT: The nurse identifies a BMi of 28 as a modifiable variable that a client can change. The nurse should provide the client with educational materials and information on weight reduction and exercising.
C. The nurse identifies alopecia as a non‑modifiable variable because alopecia is a genetic disorder.
d. The nurse identifies Trisomy 21 as a non‑modifiable variable because Trisomy 21 is genetic in origin.
e. CORRECT: The nurse identifies reflux as a modifiable variable that a client can change. The nurse should provide the client with step‑by‑step educational information about treatment.
NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention
4. A. The client’s lack of a family history of cancer can influence the client’s response to the new diagnosis, but it does not reflect a lack of understanding of an illness perspective.
B. CORRECT: The client’s statement of denial reflects a lack of understanding of the illness perspective and can influence the client’s acceptance of the diagnosis.
C. Access to health care resources can influence the client’s response to the new diagnosis, but it does not reflect a lack of understanding of an illness perspective.
d. Time constraints can influence a client’s response to the diagnosis, but it does not reflect a lack of understanding of an illness perspective.
NCLEX® Connection: Health Promotion and Maintenance, Health Screening
Active Learning Scenario Key
Using the ATI Active Learning Template: Basic Concept
RELATED CONTENT: identifying obstacles for compliance and adherence
UNDERLYING PRINCIPLES: Health promotion and disease prevention are influenced by many factors that a nurse should address for a client’s success.
NURSING INTERVENTIONS ● Provide the client with resources to strengthen coping abilities. ● encourage use of support systems (family, support group). ● identify ways to improve compliance. ● develop health education methods to reduce health risks. ● identify the client’s obstacles to health and wellness. ● Create strategies to reduce the client’s obstacles.
NCLEX® Connection: Health Promotion and Maintenance, High Risk Behaviors
6 CHAPTER 1 HeALTH, WeLLNess, ANd iLLNess CONTENT MASTERY SERIES
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 2 eMerGeNCy NUrsiNG PriNCiPLes ANd MANAGeMeNT 7
UNIT 1 FOUNDATIONS OF NURSING CARE FOR ADULT CLIENTS
CHAPTER 2 Emergency Nursing Principles and Management
emergency nursing principles are the guidelines that nurses follow to assess and manage emergency situations for a client or multiple clients.
Nurses must have the ability to identify emergent situations and rapidly assess and intervene when life‑threatening conditions exist. emergent conditions are common to all nursing environments.
emergency nursing principles: triage, primary survey, the ABCde principle, poisoning, rapid response team, cardiac emergency, and postresuscitation.
emergency departments often implement the five‑level system of triage: resuscitation (level one), emergent (level two), urgent (level three), less urgent (level four), and nonurgent (level five). Time and experience are required for the nurse to become an effective member of the triage team. The nurse, provider, and other members of the health care team work together in the triage area to determine the needs of the client.
resuscitation triage requires immediate treatment to prevent death.
Nonurgent is a non‑life‑threatening condition requiring simple evaluation and care management.
PRIMARY SURVEY ● A primary survey is a rapid assessment of
life-threatening conditions. ● The primary survey should be completed systematically
so life-threatening conditions are not missed. ● Standard precautions—gloves, gowns, eye protection,
face masks, and shoe covers—must be worn to prevent contamination with bodily fluids.
● The ABCDE principle guides the primary survey.
ABCDE PRINCIPLE
AirWAy/CerViCAL sPiNe ● This is the most important step in performing the
primary survey. If a patent airway is not established, subsequent steps of the primary survey are futile. As a result of hypoxia, brain injury or death will occur within 3 to 5 min if the airway is not patent.
● If a client is awake and responsive, the airway is open. ● If a client’s ability to maintain an airway is lost, it is
important to inspect for blood, broken teeth, vomitus, or other foreign materials in the airway that can cause an obstruction.
● If the client is unresponsive without suspicion of trauma, the airway should be opened with a head-tilt/chin-lift maneuver.
◯ Do NOT perform this technique on clients who have a potential cervical spine injury.
◯ To perform the head-tilt/chin-lift maneuver, the nurse should assume a position at the head of the client, place one hand on his forehead, and place the other hand underneath the client’s chin. His head should be tilted while his chin is lifted upward and forward. This maneuver lifts the tongue away from the laryngopharynx and provides for a patent airway.
● If the client is unresponsive with suspicion of trauma, the airway should be opened with a modified jaw thrust maneuver.
◯ The nurse should assume a position at the head of the client and place both hands on either side of the client’s head. Locate the connection between the maxilla and the mandible. Lift the jaw superiorly while maintaining alignment of the cervical spine.
● Once the airway is opened, it should be inspected for blood, broken teeth, vomitus, and secretions. If present, obstructions should be cleared with suction or a finger-sweep method if the object is clearly visible.
● The open airway can be maintained with airway adjuncts, such as an oropharyngeal or nasopharyngeal airway.
● A bag valve mask with a 100% oxygen source is indicated for clients who need additional support during resuscitation until an advanced airway is established.
● A nonrebreather mask with 100% oxygen source is indicated for clients who are spontaneously breathing.
BreATHiNGOnce a patent airway is achieved, the nurse should assess for the presence and effectiveness of breathing.
BREATHING ASSESSMENT ● Auscultation of breath sounds ● Observation of chest expansion and respiratory effort ● Notation of rate and depth of respirations ● Identification of chest trauma ● Assessment of tracheal position ● Assessment for jugular vein distention
If a client is not breathing or is breathing inadequately , manual ventilation should be performed by a bag valve mask with supplemental oxygen or mouth-to-mask ventilation until a bag valve mask can be obtained.
CHAPTER 2
8 CHAPTER 2 eMerGeNCy NUrsiNG PriNCiPLes ANd MANAGeMeNT CONTENT MASTERY SERIES
CirCULATiON ● Once adequate ventilation is accomplished, circulation
is assessed. ● Nurses should assess heart rate, blood pressure,
peripheral pulses, and capillary refill for adequate perfusion.
● Nurses should consider cardiac arrest, myocardial dysfunction, and hemorrhage as precursors to shock and leading to ineffective circulation.
● Shock can develop if circulation is compromised. Shock is the body’s response to inadequate tissue perfusion and oxygenation. It manifests with an increased heart rate and hypotension and can result in tissue ischemia and necrosis.
NURSING ACTIONS ● Interventions for restoring effective circulation:
◯ Perform CPR. ◯ Assess for external bleeding. ◯ Hemorrhage control: Apply direct pressure to visible, significant external bleeding.
◯ Obtain IV access using large-bore IV catheters inserted into the antecubital fossa of both arms, unless there is obvious injury to the extremity.
◯ Infuse isotonic IV fluids such as lactated Ringer’s and 0.9% sodium chloride, and/or blood products.
● Interventions to alleviate shock ◯ Administer oxygen. ◯ Apply pressure to obvious bleeding. ◯ Elevate lower extremities to shunt blood to vital organs.
◯ Administer IV fluids and blood products. ◯ Monitor vital signs. ◯ Remain with the client, and provide reassurance and support for anxiety.
disABiLiTyDisability is a quick assessment to determine the client’s level of consciousness.
● The AVPU mnemonic is useful. (2.1) ● The Glasgow Coma Scale is another widely-used
method. (2.2) ● Neurologic assessment must be repeated at frequent
intervals to ensure immediate response to any change.
FrOsTBiTe ● Skin condition which occurs after prolonged exposure to
freezing temperatures. ● Extent of injury to exposed skin may not be evident
for at least 24 hr after injury and is categorized as superficial (first degree), partial thickness (second degree), or full thickness (third and fourth degree).
◯ 1st degree: Least severe form. Only superficial layers of exposed skin are affected with hyperemia and edema.
◯ 2nd degree: Blisters cover the exposed skin areas causing necrotic tissue death and swelling.
◯ 3rd degree: Extensive edema and blisters to the affected skin which does not blanch. Affected areas will be treated by debridement of damaged tissue.
◯ 4th degree: The affected area completely lacks blood supply and is considered full thickness necrosis of skin with potential progression to gangrene. The extent of the gangrene may require amputation of affected areas.
NURSING ACTIONS ● Clients require rewarming. Bathing affected areas in
warm bath (104º to 108º F [40º to 42º C]) will improve blood circulation and promote healing of damaged tissue. This rewarming process can increase pain as circulation improves to affected areas of skin.
● Administer tetanus toxoid IM vaccine to prevent complications related to growth of tetanus in wounds.
eXPOsUre ● The nurse removes the client’s clothing for a complete
physical assessment. The nurse might need to cut off the client’s clothing to accomplish this task.
● Clothing is always removed during a resuscitation situation to assess for additional injuries or those related to chemical and thermal burns involving the clothing.
● The nurse should preserve items of evidence (clothing, bullets, drugs, weapons).
● Hypothermia is a primary concern. Hypothermia occurs when the client’s core temperature is 35° C (95° F) or less.
● Victims of trauma are at risk for hypothermia due to exposure, unwarmed oxygen, and cold IV fluids.
● Hypothermia can lead to eventual coma, hypoxemia, and acidosis.
2.1 AVPU mnemonic
A AlertV Responsive to voiceP Responsive to painU Unresponsive
2.2 Glasgow Coma Scale
EYE‑OPENING RESPONSEspontaneous 4To voice 3To pain 2None 1
VERBAL RESPONSEOriented 5Confused 4inappropriate words 3incomprehensible sounds 2None 1
MOTOR RESPONSEObeys commands 6Localizes pain 5Withdraws 4Flexion 3extension 2None 1
A low score of 3 indicates a client who is totally unresponsive, and a high score of 15 indicates a client who is within normal limits neurologically.
+ +
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 2 eMerGeNCy NUrsiNG PriNCiPLes ANd MANAGeMeNT 9
To prevent hypothermia: ● Remove wet clothing from the client. ● Cover the client with warm blankets. ● Increase the temperature of the room. ● Use a heat lamp to provide additional warmth. ● Infuse warmed IV fluids.
HeAT eXHAUsTiON ● Heat exhaustion occurs after prolonged exposure to
elevated temperatures and causes excessive diaphoresis and tachycardia leading to dehydration.
● Clients must receive rapid treatment for the dehydration and low sodium to prevent developing heat stroke.
HeAT sTrOKeHeat stroke is a medical emergency and clients must receive immediate treatment to prevent death.
MANIFESTATIONS ● Elevated temperature (greater than 40° C [104° F]) ● Lack of perspiration ● Low blood pressure ● Increased heart rate ● Decreased urinary output ● Alterations in mental status ● Abnormal blood potassium or sodium levels
NURSING ACTIONS ● Priority is to assess using ABCDE. ● Administer oxygen as needed. ● Insert large-gauge IV catheter for rapid intravenous
administration of 0.9% sodium chloride. ● Client can require indwelling urinary catheter. ● Apply ice packs and cooling blankets.
To prevent hyperthermia ● Wear lightweight, loose-fitting clothing. ● Avoid excessive sun exposure. ● Stay indoors with fans or air conditioning when outside
temperatures are elevated. ● Limit consumption of alcohol and caffeine. ● Apply sunscreen of at least 30 SPF. ● If overheated, take a cool water shower or bath.
POisONiNGPoisoning is exposure to a toxic agent.
● Medications, illicit drugs, ingestion of a toxic agent ● Environmental (pollutants, snake and spider bites)
Poisoning is considered a medical emergency and requires rapid management therapy.
● Obtain a client history to identify the toxic agent. ● Implement supportive care. ● Determine type of poison. ● Prevent further absorption of the toxin. ● Extract or remove the poison. ● Administer antidotes when necessary. ● A snakebite from a venomous snake is a
medical emergency. ◯ Children ages 1 to 9 are at highest risk for snakebites. ◯ The nurse should be familiar with indigenous snakes in the community.
◯ Generally, ice, tourniquets, heparin, and corticosteroids are contraindicated in the first 6 to 8 hr after the bite.
◯ Antivenom based on the type and severity of a snake bite is most effective if administered within 4 to 12 hr.
Interventions to manage the clinical status of the client exposed to or who ingested a toxic agent:
● Provide measures for respiratory support (oxygen, airway management, mechanical ventilation).
● Monitor compromised circulation (resulting from excess perspiration, vomiting, diarrhea).
● Restore fluids with IV fluid therapy. ● Monitor blood pressure, cardiac monitoring, ECG. ● Assess for tissue edema every 15 to 30 min if bitten by a
snake or spider. ● Administer opioid medications for pain due to snake or
spider bite. ● Monitor ABGs, blood glucose levels, coagulation profile. ● For ingested poison, three procedures are available:
activated charcoal, gastric lavage (if done within 1 hr of ingestion), and aspiration. Syrup of ipecac is no longer recommended.
● Administer diazepam if seizures occur. ● Reverse heroin and other opiate toxicity with naloxone. ● Implement dialysis and an exchange blood transfusion
as a nonpharmacologic technique to remove toxic agents.
2.3 Common causes of pulseless electrical activity
5 H’sHypovolemiaHypoxiaHydrogen ion accumulation, resulting in acidosisHyperkalemia or hypokalemiaHypothermia
5 T’sToxins (accidental or deliberate drug overdose)Tamponade (cardiac)Tension pneumothoraxThrombosis (coronary)Thrombosis (pulmonary)
2.4 Receptor sites and responses
Alpha1Activation of receptors in arterioles of skin, viscera and mucous membranes, and veins lead to vasoconstriction
Beta1Heart stimulation leads to increased heart rate, increased myocardial contractility, and increased rate of conduction through the atrioventricular (AV) node.Activation of receptors in the kidney leads to the release of renin.
Beta2Bronchial stimulation leads to bronchodilation.Activation of receptors in uterine smooth muscle causes relaxation.Activation of receptors in the liver causes a breakdown of glycogen into glucose.skeletal muscle receptor activation leads to muscle contraction, which can lead to tremors.
DopamineActivation of receptors in the kidney cause the renal blood vessels to dilate.
10 CHAPTER 2 eMerGeNCy NUrsiNG PriNCiPLes ANd MANAGeMeNT CONTENT MASTERY SERIES
RAPID RESPONSE TEAM ● The team is a group of critical care experts (ICU nurse,
respiratory therapist, critical care provider, hospitalist).
● Responds to an emergency call from nurses or family members when a client exhibits indications of a rapid decline.
● Provides early recognition and response before a respiratory or cardiac arrest or stroke occurs.
● Policies and procedures are established in a health care setting.
● Training for personnel is provided about criteria for calling for assistance when a client’s condition changes toward a crisis situation.
● SBAR (Situation, Background, Assessment, Recommendation) communication techniques are used for contacting the team and documentation of event.
● Implement follow-up, education, and sharing of information (debriefing) for participants after the call.
● Discuss information to identify system failures (not recognizing a crisis, lack of adequate communication, failure in the plan of care).
● Retrieve more information at www.ihi.org.
CARDIAC EMERGENCYCardiac arrest: the sudden cessation of cardiac function caused most commonly by ventricular fibrillation or ventricular asystole.
Ventricular fibrillation (VF): a fluttering of the ventricles causing loss of consciousness, pulselessness, and no breathing. This requires collaborative care to defibrillate immediately using ACLS protocol.
Pulseless ventricular tachycardia (VT): an irritable firing of ectopic ventricular beats at a rate of 140 to 180/min. The client over time will become unconscious and deteriorate into VF.
Ventricular asystole: a complete absence of electrical activity and ventricular movement of the heart. The client is in complete cardiac arrest and requires implementation of BLS and ACLS protocol.
Pulseless electrical activity (PEA): a rhythm that appears to have electrical activity but is not sufficient to stimulate effective cardiac contractions and requires implementation of BLS and ACLS protocol.
Emergency nurse certifications ● Basic Life Support (BLS), Advanced Cardiac Life Support
(ACLS), and Pediatric Advanced Life Support (PALS) are certifications required for nurses practicing in United States emergency departments.
● BLS involves a hands-on approach for assessment and management to restore airway, breathing, and circulation.
● ACLS builds on the BLS assessment and management skills to include advanced concepts.
◯ Cardiac monitoring for specific resuscitation rhythms ◯ Invasive airway management ◯ Electrical therapies (defibrillation or cardioversion) ◯ Obtaining IV access ◯ Administration of IV antidysrhythmic medications ◯ Management of the client postresuscitation
● PALS is built on the BLS protocol for neonatal and pediatric assessment and management skills to include advanced concepts for resuscitation of children.
● Certification courses are based on evidence-based practice management theory, and the basic concepts and techniques for cardiopulmonary resuscitation (CPR).
● Current BLS and ACLS guidelines are available from the American Heart Association (AHA) at www.heart.org.
AHA ACLs PrOTOCOLsVF or pulseless VT
● Initiate the CPR components of BLS. ● Defibrillate according to BLS guidelines. ● Establish IV access. ● Administer IV antidysrhythmic medications,
such as epinephrine or vasopressin, according to ACLS guidelines.
● Consider the following medications: ◯ Amiodarone hydrochloride ◯ Lidocaine hydrochloride ◯ Magnesium sulfate
2.5 Food interactions
MAOIs promote the release of norepinephrine from sympathetic nerves and thereby prolong and intensify the effects of epinephrine and can cause hypertensive crisis.
NURSING INTERVENTIONS: Avoid the use of MAOis in clients who are receiving epinephrine.
Tricyclic antidepressants block the uptake of epinephrine, which will prolong and intensify the effects of epinephrine.NURSING INTERVENTIONS: Clients taking these medications concurrently can need a lower dose of epinephrine.
General anesthetics can cause the heart to become hypersensitive to the effects of epinephrine, which leads to dysrhythmias.
NURSING INTERVENTIONSPerform continuous eCG monitoring.Notify the provider if the client experiences chest pain, dysrhythmias, or an elevated heart rate.
Beta‑adrenergic blocking agents, such as propranolol, block the action at beta receptors.
NURSING INTERVENTIONS: Propranolol may be used to treat chest pain, hypertension, myocardial infarction, and dysrhythmias.
Diuretics promote the beneficial effect of dopamine.
NURSING INTERVENTIONS: Monitor for therapeutic effects.
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 2 eMerGeNCy NUrsiNG PriNCiPLes ANd MANAGeMeNT 11
2.6 Emergency medications
RECEPTORSPHARMACOLOGICAL ACTION THERAPEUTIC USE ADVERSE EFFECTS NURSING ACTIONS
Epinephrine
Alpha1 Vasoconstriction
slows absorption of local anestheticsManages superficial bleedingreduces congestion of nasal mucosaincreases blood pressure
Vasoconstriction from activation of alpha1 receptors in the heart can lead to hypertensive crisis.
Provide continuous cardiac monitoring.report changes in vital signs to the provider.
Beta1
increases heart ratestrengthens myocardial contractilityincreases rate of conduction through the AV node
Treatment of AV block and cardiac arrest
Beta1 receptor activation in the heart can cause dysrhythmias. Beta1 receptor activation also increases the workload of the heart and oxygen demand, leading to the development of angina.
Provide continuous cardiac monitoring.Monitor closely for dysrhythmias, change in heart rate, and chest pain.Monitor for hyperglycemia in clients who have diabetes mellitus.Notify the provider if the client experiences dysrhythmias, an elevated heart rate, or chest pain, and treat per protocol.Beta2 Bronchodilation Asthma
The activation of beta2 receptors in the liver and skeletal muscles can cause hyperglycemia from the breakdown of glycogen.
Dopamine
dopamine
Low dose – dopamine (2 to 5 mcg/kg/min)renal blood vessel dilation
shockHeart failureAcute kidney injury
Beta1
Moderate dose – dopamine (5 to 10 mcg/kg/min)renal blood vessel dilationincreases:
● Heart rate ● Myocardial contractility ● rate of conduction through the AV node
● Blood pressure
Beta1 receptor activation in the heart can cause dysrhythmias. Beta1 receptor activation also increases the workload of the heart and oxygen demand, leading to the development of angina.
Provide continuous cardiac monitoring.Monitor closely for dysrhythmias, change in heart rate, and chest pain. Notify the provider of manifestations of dysrhythmias, elevated heart rate, and chest pain, and treat per protocol.Monitor for urinary output less than 30 mL/hr.do not confuse dopamine with dobutamine.
Beta1
Alpha1
High dose – dopamine (greater than 10 mcg/kg/min)renal blood vessel vasoconstrictionincreases:
● Heart rate ● Myocardial contractility ● rate of conduction through the AV node
● Blood pressure ● Vasoconstriction
Necrosis can occur from extravasation due to high doses of dopamine.
infuse dopamine into the central line. Monitor the iV site carefully. discontinue the infusion at first indication of irritation.
Dobutamine
Beta1
increases: ● Heart rate ● Myocardial contractility ● rate of conduction through the AV node
Heart failure increased heart rate
Provide continuous cardiac monitoring. report changes in vital signs to the provider.Monitor for urinary output less than 30 mL/hr.do not confuse dobutamine with dopamine.
12 CHAPTER 2 eMerGeNCy NUrsiNG PriNCiPLes ANd MANAGeMeNT CONTENT MASTERY SERIES
Pulseless electrical activity (PEA) ● Initiate the CPR components of BLS. ● If shockable rhythm, defibrillate according to
BLS guidelines. ● Establish IV access. ● Consider the most common causes. (2.3) ● Administer epinephrine 1 mg IV push every 3 to 5 min. ● Asystole
◯ Initiate the CPR components of BLS. ◯ Establish IV access. ◯ Give epinephrine 1 mg IV push every 3 to 5 min. ◯ Consider reversible causes. ◯ Asystole is often the final rhythm as the electrical and mechanical activity of the heart has stopped. The provider should consider ceasing resuscitation if asystole persists.
POsTresUsCiTATiONPHARMACOLOGICAL MANAGEMENT
● Medication therapy following a successful cardiac arrest includes IV medications that cause a catecholamine adrenergic agonist’s effect.
● Catecholamine adrenergic agonists cannot be taken by the oral route, do not cross the blood-brain barrier, and have a short duration of action.
● Medications include epinephrine, dopamine, and dobutamine.
● These medications respond to an identifiable receptor and produce specific effects.
CONTRAINDICATIONS/PRECAUTIONS ● Pregnancy Risk Category C: epinephrine, dopamine,
dobutamine. ● These medications are contraindicated in clients who
have tachydysrhythmias and ventricular fibrillation. ● Use cautiously in clients who have hyperthyroidism,
angina, history of myocardial infarction, hypertension, and diabetes mellitus.
NURSING ACTIONS ● Administer medications by continuous IV infusion. ● Use IV pump to control infusion. ● Titrate dosage based on blood pressure response and/or
heart rate response. (These medications affect heart rate and blood pressure.)
● Stop the infusion at the first indication of infiltration. Extravasation can be treated with a local injection of an alpha-adrenergic blocking agent, such as phentolamine.
● Assess/monitor for chest pain. Notify the provider if the client experiences chest pain.
● Provide continuous ECG monitoring. Notify the provider if the client experiences tachycardia or dysrhythmias.
Application Exercises
1. A nurse on a medical‑surgical unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients?
A. Client who has a pressure injury of the right heel whose blood glucose is 300 mg/dL
B. Client who reports right calf pain and shortness of breath
C. Client who has blood on a pressure dressing in the femoral area following a cardiac catheterization
d. Client who has dark red coloration of left toes and absent pedal pulse
2. A nurse is caring for a client who has ingested a toxic agent. Which of the following actions should the nurse plan to take? (select all that apply.)
A. induce vomiting.
B. instill activated charcoal.
C. Perform a gastric lavage with aspiration.
d. Administer syrup of ipecac.
e. infuse iV fluids.
3. A nurse in the emergency department is caring for a client who fell through the ice on a pond and is unresponsive and breathing slowly. Which of the following actions should the nurse take? (select all that apply.)
A. remove wet clothing.
B. Maintain normal room temperature.
C. Apply warm blankets.
d. Use a rapid rewarming water of 40º to 42º C (104º to 108º F).
e. infuse warmed iV fluids.
4. A nurse in the emergency department is assessing a client who is unresponsive. The client’s partner states, “He was pulling weeds in the yard and slumped to the ground.” Which of the following techniques should the nurse use to open the client’s airway?
A. Head‑tilt, chin‑lift
B. Modified jaw thrust
C. Hyperextension of the head
d. Flexion of the head
5. A nurse is reviewing the common emergency management protocol for clients who have asystole. Which of the following actions should the nurse plan to take during this cardiac emergency?
A. Perform defibrillation.
B. Prepare for transcutaneous pacing.
C. Administer iV epinephrine.
d. elevate the client’s lower extremities.
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 22 eMerGeNCy NUrsiNG PriNCiPLes ANd MANAGeMeNTeMerGeNCy NUrsiNG PriNCiPLes ANd MANAGeMeNT 13
Active Learning Scenario
A nurse in the emergency department (ed) is implementing triage using the five‑level system. Use the ATi Active Learning Template: Basic Concept to complete this item.
RELATED CONTENT: identify the five levels of the ed triage system.
UNDERLYING PRINCIPLES: define each of the five triage levels.
NURSING INTERVENTIONS: describe a client who meets the criteria for each of the five triage levels.
Application Exercises Key
1. A. The nurse should notify the provider. The situation does not indicate the beginning of a rapid decline in the client’s condition.
B. CORRECT: The nurse should identify that the client is at risk for respiratory arrest due to a possible embolism. The nurse should call the rapid response team because the manifestations can indicate the beginning of a rapid decline in the client’s condition.
C. This assessment does not indicate the beginning of a rapid decline in the client’s condition at this time. The nurse should reassess the client and notify the provider if the bleeding increases.
d. The nurse should notify the provider. The situation does not indicate the beginning of a rapid decline in the client’s condition.
NCLEX® Connection: Physiological Adaptation, Medical Emergencies
2. A. Vomiting places the client at risk for aspiration.B. CORRECT: This is an appropriate action by the nurse
because activated charcoal adsorbs toxic substances, and the charcoal does not pass into the bloodstream.
C. CORRECT: This is an appropriate action by the nurse because gastric lavage with aspiration removes the toxic substance when the instilled fluid is suctioned from the gastrointestinal tract.
d. Administering syrup of ipecac is not recommended because it induces vomiting, which increases the client’s risk for aspiration.
e. CORRECT: This is an appropriate action by the nurse because intravenous fluids help dilute the toxic substances in the bloodstream and promote elimination from the body through the kidneys.
NCLEX® Connection: Physiological Adaptation, Medical Emergencies
3. A. CORRECT: This is an appropriate action by the nurse because the body temperature can rise more quickly when heat is applied to dry skin.
B. The nurse should increase the temperature of the room to help return the client to a normal body temperature.
C. CORRECT: This is an appropriate action by the nurse because the client’s body temperature can rise more quickly when warm blankets are applied.
d. CORRECT: This is an appropriate action by the nurse because the client’s body temperature can rise more quickly when a rapid rewarming bath water of 40º to 42º C (104º to 108º F) is used to warm the client’s body and preserve tissues.
e. CORRECT: This is an appropriate action by the nurse because the client’s body temperature can rise more quickly when warmed iV fluids are infused.
NCLEX® Connection: Physiological Adaptation, Medical Emergencies
4. A. CORRECT: The nurse should open the client’s airway by the head‑tilt, chin‑lift because the client is unresponsive without suspicion of trauma.
B. The nurse should not open the client’s airway with the modified jaw thrust because this method is used for a client who is unresponsive with suspected traumatic neck injury.
C. The nurse should not open the client’s airway with hyperextension of the head because hyperextension of the head can close off the airway and cause injury.
d. The nurse should not open the client’s airway with flexion of the head because flexion of the head does not open the airway.
NCLEX® Connection: Physiological Adaptation, Medical Emergencies
5. A. defibrillation is not indicated for asystole, because this is not considered a shockable cardiac rhythm.
B. Transcutaneous pacing is not indicated for the treatment of asystole.
C. CORRECT: Administering epinephrine during asystole is an appropriate action by the nurse because it increases heart rate, improves cardiac output, and promotes bronchodilation.
d. elevating the client’s lower extremities is indicated for the treatment of a client who is in shock, rather than asystole.
NCLEX® Connection: Physiological Adaptation, Medical Emergencies
14 CHAPTER 22 eMerGeNCy NUrsiNG PriNCiPLes ANd MANAGeMeNTeMerGeNCy NUrsiNG PriNCiPLes ANd MANAGeMeNT CONTENT MASTERY SERIES
Active Learning Scenario Key
Using the ATI Active Learning Template: Basic Concept
RELATED CONTENT ● resuscitation ● emergent ● Urgent ● Less Urgent ● Nonurgent
UNDERLYING PRINCIPLES ● resuscitation: The client needs immediate treatment to prevent death. ● emergent: The client requires time sensitive treatment for a problem that has the potential to become a life or limb‑threatening situation. ● Urgent: The client requires treatment but the situation is not life‑threatening. ● Less Urgent: The client is able to wait for a period of time without immediate treatment. ● Nonurgent: The client requires simple evaluation and minor management of care.
NURSING INTERVENTIONS ● resuscitation: A client who is experiencing cardiac arrest, stroke, pulmonary emboli, or drug overdose. ● emergent: A client who has sustained a traumatic amputation, head or neck injury, snake or spider bite. ● Urgent: A client who has a kidney stone, gallbladder colic, or fracture. ● Less Urgent: A client who has a bladder infection, laceration, or infected toe. ● Nonurgent: A client who has a rash, minor cut, or backache.
NCLEX® Connection: Physiological Adaptation, Medical Emergencies
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RN ADULT MEDICAL SURGICAL NURSING NCLeX® CONNeCTiONs 15
NCLEX® Connections
When reviewing the following chapters, keep in mind the relevant topics and tasks of the NCLEX outline, in particular:
Basic Care and ComfortNON-PHARMACOLOGICAL COMFORT INTERVENTIONS: Provide non-pharmacological comfort measures.
MOBILITY/IMMOBILITY: Assess the client for mobility, gait, strength, and motor skills.
NUTRITION AND ORAL HYDRATIONEvaluate client intake and output and intervene as needed.
Evaluate the impact of disease/illness on nutritional status of a client.
Physiological AdaptationALTERATIONS IN BODY SYSTEMS: Apply knowledge of nursing procedures, pathophysiology and psychomotor skills when caring for a client with an alteration in body systems.
ILLNESS MANAGEMENT: Implement interventions to manage the client’s recovery from an illness.
Pharmacological and Parenteral TherapiesADVERSE EFFECTS/CONTRAINDICATIONS/SIDE EFFECTS/INTERACTIONS Assess the client for actual or potential side effects and adverse effects of medications.
Apply knowledge of nursing procedures and psychomotor skills when caring for a client with potential for complications.
EXPECTED ACTIONS/OUTCOMES: Evaluate
CLIENT RESPONSE TO MEDICATION.
PHARMACOLOGICAL PAIN MANAGEMENTAssess client need for administration of a PRN pain medication.
Administer medications for pain management.
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16 NCLeX® CONNeCTiONs CONTENT MASTERY SERIES
Reduction of Risk PotentialDIAGNOSTIC TESTS: Compare client diagnostic findings with pretest results.
POTENTIAL FOR COMPLICATIONS OF DIAGNOSTIC TESTS/TREATMENTS/PROCEDURES: Use precautions to prevent injury and/or complications associated with a procedure or diagnosis.
THERAPEUTIC PROCEDURES: Apply knowledge of related nursing procedures and psychomotor skills when caring for clients undergoing therapeutic procedures.
Safety and Infection ControlSTANDARD PRECAUTIONS/TRANSMISSION-BASED PRECAUTIONS/SURGICAL ASEPSIS: Apply principles of infection control.
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 3 NeUrOLOGiC diAGNOsTiC PrOCedUres 17
UNIT 2 NEUROLOGIC DISORDERSSECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES
CHAPTER 3 Neurologic Diagnostic Procedures
Neurologic assessment and diagnostic procedures are used to evaluate neurologic function by testing indicators such as mental status, motor functioning, electrical activity, and intracranial pressure.
Neurologic assessment and diagnostic procedures that nurses should be knowledgeable about include cerebral angiography, cerebral computed tomography (CT) scan, electroencephalography (eeG), Glasgow Coma scale (GCs), intracranial pressure monitoring, lumbar puncture (spinal tap), magnetic resonance imaging (Mri), positron emission tomography (PeT), single‑photon emission computed tomography (sPeCT), and radiography (x‑ray).
Cerebral angiographyCerebral angiography provides visualization of the cerebral blood vessels.
● Digital subtraction angiography hides the bones and tissues from the images, providing x-rays with only the vessels apparent.
● The procedure detects defects, narrowing, or obstruction of arteries or blood vessels in the brain.
● The procedure is performed within the radiology department because iodine-based contrast dye is injected into an artery during the procedure.
INDICATIONSCerebral angiography is used to assess the blood flow to and within the brain, identify aneurysms, and define the vascularity of tumors (useful for surgical planning). It is also used therapeutically to inject medications that treat blood clots or to administer chemotherapy.
CONSIDERATIONS
PrePrOCedUreIf the client is pregnant, a determination of the risks to the fetus versus the benefits of the information obtained by this procedure should be made.
NURSING ACTIONS ● Instruct the client to refrain from consuming food or
fluids for 4 to 6 hr prior to the procedure. ● Assess for history of allergies. ● Any history of bleeding or taking anticoagulant
medication requires additional considerations and additional monitoring to ensure clotting after the procedure.
● Assess BUN and blood creatinine to determine the kidney’s ability to excrete the dye.
● Ensure that the client is not wearing any jewelry. ● A mild sedative for relaxation is occasionally
administered prior to and during the procedure, and vital signs are continuously monitored during the procedure.
CLIENT EDUCATION ● The head will be immobilized during the procedure, and
it is important to remain still. ● Void immediately prior to the procedure. ● Following dye injection, it is common to experience a
metallic taste and feel a sensation of warmth behind the eyes, and over the face, jaw, tongue, and lips.
iNTrAPrOCedUre ● The client is placed on a radiography table, where the
client’s head is secured. ● A catheter is placed into an artery (usually in the groin
or the neck), dye is injected, and x-ray pictures are taken. ● Once all pictures are taken, the catheter is removed and
an arterial closure device is used or pressure is held over the artery to control bleeding by thrombus formation sealing the artery.
POsTPrOCedUreNURSING ACTIONS
● Closely monitor the area to ensure that clotting occurs. ● Movements are restricted depending on the type of
procedure used to seal the artery to prevent rebleeding at the catheter site.
● Place an ice pack on the insertion site.
COMPLICATIONSThere is a risk for bleeding or hematoma formation at the entry site.
NURSING ACTIONS ● Check the insertion site frequently. ● Check the affected extremity distal to the puncture
site for adequate circulation (color, temperature, pulses, capillary refill).
● If bleeding occurs, apply pressure over the artery and notify the provider.
CHAPTER 3
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Cerebral computed tomography scan
A CT scan provides cross-sectional images of the cranial cavity. A contrast medium can be used to enhance the images.
INDICATIONSCT scanning can be used to identify tumors and infarctions, detect abnormalities, monitor response to treatment, and guide needles used for biopsies.
CONSIDERATIONS
PrePrOCedUreIf the client is pregnant, a determination of the risks to the fetus versus the benefits of the information obtained by this procedure should be made.
NURSING ACTIONS ● If contrast media and/or sedation is expected:
◯ Instruct the client to refrain from consuming food or fluids for at least 4 hr prior to the procedure.
◯ Assess for allergy to shellfish or iodine, which would require the use of a different contrast media.
◯ Assess BUN and creatinine because contrast media is excreted by the kidneys.
● Because this procedure is performed with the client in a supine position, placing pillows in the small of the client’s back can assist in preventing back pain. The head must be secured to prevent unnecessary movement during the procedure.
● Ensure that the client’s jewelry is removed prior to this procedure. In general, clients wear a hospital gown to prevent any metals from interfering with the x-rays.
iNTrAPrOCedUre ● The client must lie supine with the head stabilized
during the procedure. ● Although CT scanning is painless, sedation can
be provided.
POsTPrOCedUreNURSING ACTIONS
● There is no follow-up care associated with a CT scan. ● If contrast media is injected, monitor for allergic
reaction and changes in kidney function. ● If sedation is administered, monitor the client
until stable.
ElectroencephalographyAn EEG is a noninvasive procedure that assesses the electrical activity of the brain and is used to determine abnormalities in brain wave patterns. An EEG provides information about the ability of the brain to function and highlights areas of abnormality.
INDICATIONSEEGs are most commonly performed to identify and determine seizure activity, but they are also useful for detecting sleep disorders and behavioral changes.
CONSIDERATIONS
PrePrOCedUreNURSING ACTIONS: Review medications with the provider to determine if they should be continued prior to this procedure.
CLIENT EDUCATION ● Wash the hair to eliminate all oils, gels, and sprays. ● Stay awake prior to the test. Being sleep-deprived
provides cranial stress, increasing the possibility of abnormal electrical activity, such as seizure potentials, occurring during the procedure.
● To stimulate electrical activity during the test, you might be exposed to bright flashing lights, or asked to hyperventilate for 3 to 4 min.
● Avoid taking any stimulant or sedative medication 12 to 24 hr prior to the procedure.
iNTrAPrOCedUre ● The procedure generally takes 45 to 120 min. ● There are no risks associated with this procedure. ● With the client resting in a chair or lying in bed, small
electrodes are placed on the scalp and connected to a brain wave machine or computer.
● Electrical signals produced by the brain are recorded by the machine or computer in the form of wavy lines. This documents brain activity.
● Notations are made when stimuli are presented or when sleep occurs. (Flashes of light or pictures can be used during the procedure to assess the client’s response to stimuli.)
POsTPrOCedUreCLIENT EDUCATION: Resume your normal activities and routine.
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 3 NeUrOLOGiC diAGNOsTiC PrOCedUres 19
Glasgow Coma ScaleThis assessment concentrates on neurologic function and is useful to determine the level of consciousness and monitor response to treatment. The Glasgow Coma Scale is reported as a number that allows providers to immediately determine if neurologic changes have occurred.
INDICATIONSGCS scores are helpful in determining changes in the level of consciousness for clients who have head injuries, space-occupying lesions or cerebral infarctions, and encephalitis. This is important because complications related to neurologic injuries can occur rapidly and require immediate treatment.
CONSIDERATIONSGCS scores are calculated by using appropriate stimuli (a painful stimulus can be necessary) and then assessing the client’s response in three areas.
● Eye opening (E): The best eye response, with responses ranging from 4 to 1
◯ 4 = Eye opening occurs spontaneously. ◯ 3 = Eye opening occurs secondary to sound. ◯ 2 = Eye opening occurs secondary to pain. ◯ 1 = Eye opening does not occur.
● Verbal (V): The best verbal response, with responses ranging from 5 to 1
◯ 5 = Conversation is coherent and oriented. ◯ 4 = Conversation is incoherent and disoriented. ◯ 3 = Words are spoken, but inappropriately. ◯ 2 = Sounds are made, but no words. ◯ 1 = Vocalization does not occur.
● Motor (M): The best motor response, with responses ranging from 6 to 1
◯ 6 = Commands are followed. ◯ 5 = Local reaction to pain occurs. ◯ 4 = General withdrawal from pain. ◯ 3 = Decorticate posture (adduction of arms, flexion of elbows and wrists) is present.
◯ 2 = Decerebrate posture (abduction of arms, extension of elbows and wrists) is present.
◯ 1 = Motor response does not occur.Responses within each subscale are added, with the total score quantitatively describing the client’s level of consciousness. E + V + M = Total GCS
● In critical situations, where head injury is present and close monitoring is required, subscale results may also be documented. Thus, a GCS may be reported as either a single number, indicating the sum of the subscales (3 to 15), or as 3 numbers, one from each subscale result, and the total (E3 V3 M4 = GCS 10). This allows providers to determine specific neurologic function.
● Intubation limits the ability to use GCS summed scores. If intubation is present, the GCS may be reported as two scores, with modification noted. This is generally reported by totaling the eye and motor score, and recording it with a “t”, such as “GCS 5t” (with the t representing the intubation tube).
INTERPRETATION OF FINDINGS ● The best possible GCS score is 15. In general, total scores
of the GCS correlate with the degree or level of coma. ● A score less than 8 is associated with severe head injury
and coma. ● A score of 9 to 12 indicates a moderate head injury. ● A score greater than 13 is associated with minor
head trauma.
Intracranial pressure monitoring
An intracranial pressure (ICP) monitor is a device inserted into the cranial cavity that records pressure and is connected to a monitor that shows a picture of the pressure waveforms.
● Monitoring ICP facilitates continual assessment and is more precise than vague manifestations.
● The insertion procedure is performed by a neurosurgeon in the operating room, emergency department, or critical care unit. This procedure is rarely used unless the client is comatose, so there is minimal need for pain medication and preprocedural client teaching.
Three basic types of ICP monitoring systems ● Intraventricular catheter (also called a
ventriculostomy): A fluid-filled catheter is inserted into the anterior horn of the lateral ventricles (most often on the right side) through a burr hole. The catheter is connected to a sterile drainage system with a three-way stopcock that allows simultaneous drainage of cerebrospinal fluid (CSF) and monitoring of pressures by a transducer connected to a bedside monitor.
● Subarachnoid screw or bolt: A hollow, threaded screw or bolt is placed into the subarachnoid space through a twist-drill burr hole in the front of the skull, behind the hairline. The bolt is connected by fluid-filled tubing to a transducer leveled at the approximate location of the lateral ventricles.
● Epidural or subdural sensor: A fiber-optic sensor is inserted into the epidural space through a burr hole. The fiber-optic device measures changes in the amount of light reflected from a pressure-sensitive diaphragm in the catheter tip. The cable is connected to a precalibrated monitor that displays the numerical value of ICP. This method of monitoring is noninvasive because the device does not penetrate the dura.
INDICATIONS ● ICP monitoring is useful for early identification and
treatment of increased intracranial pressure. Clients who are comatose or have GCS scores of 8 or lower are candidates for ICP monitoring.
● Manifestations of increased ICP include severe headache, deteriorating level of consciousness, restlessness, irritability, dilated or pinpoint pupils, slowness to react, alteration in breathing pattern (Cheyne-Stokes respirations, central neurologic hyperventilation, apnea), deterioration in motor function, and abnormal posturing (decerebrate, decorticate, flaccidity).
20 CHAPTER 3 NeUrOLOGiC diAGNOsTiC PrOCedUres CONTENT MASTERY SERIES
CONSIDERATIONS
PrePrOCedUreThe head is shaved around the insertion location. The site is then cleansed with an antibacterial solution.
iNTrAPrOCedUre ● Local anesthetic can be used to numb the area if the
client’s GCS indicates some level of consciousness (GCS 8 to 11).
● Insertion and care of any ICP monitoring device requires surgical aseptic technique to reduce the risk for CNS infection.
POsTPrOCedUreNURSING ACTIONS
● Maintain system integrity at all times. System contamination can cause serious, life-threatening infection.
● Inspect the insertion site at least every 24 hr for redness, swelling, and drainage. Change the sterile dressing covering the access site per facility protocol.
● ICP monitoring equipment must be balanced and recalibrated per facility protocols.
● After the insertion procedure, observe ICP waveforms, noting the pattern of waveforms and monitoring for increased ICP (a sustained elevation of pressure greater than 15 mm Hg).
● Assess the client’s clinical status and monitor routine and neurologic vital signs every hour as needed.
INTERPRETATION OF FINDINGSNormal ICP is 10 to 15 mm Hg. Persistent elevation of ICP minimizes cerebral circulation, which will result in brain death if not treated urgently.
COMPLICATIONSThe insertion and maintenance of an ICP monitoring system can cause infection and bleeding.
NURSING ACTIONS ● Follow strict surgical aseptic technique. ● Perform sterile dressing changes per facility protocol. ● Keep drainage systems closed. ● Limit monitoring to 3 to 5 days. ● Irrigate the system only as needed to maintain patency.
Lumbar puncture (spinal tap)A lumbar puncture is a procedure during which a small amount of CSF is withdrawn from the spinal canal and then analyzed to determine its constituents.
INDICATIONSThis procedure is used to detect the presence of some diseases (multiple sclerosis, syphilis, meningitis), infection, and malignancies. A lumbar puncture may also be used to reduce CSF pressure, instill a contrast medium or air for diagnostic tests, or administer medication or chemotherapy directly to spinal fluid.
CONSIDERATIONS
PrePrOCedUreThe risks versus benefits of a lumbar puncture should be discussed with the client prior to this procedure.
● A lumbar puncture can be associated with rare but serious complications, such as brain herniation, especially when performed in the presence of increased ICP.
● Lumbar punctures for clients who have bleeding disorders or who are taking anticoagulants can result in bleeding that compresses the spinal cord.
NURSING ACTIONS ● Ensure that all of the client’s jewelry is removed and
that the client is wearing only a hospital gown. ● Instruct the client to void prior to the procedure. ● Clients should be positioned to stretch the spinal
canal. This can be done by having the client assume a “cannonball” position while on one side. (3.1)
iNTrAPrOCedUre ● The area of the needle insertion is cleansed, and a local
anesthetic is injected. ● The needle is inserted and the CSF is withdrawn, after
which the needle is removed. ● A manometer can be used to determine the opening
pressure of the spinal cord, which is useful if increased pressure is a consideration.
POsTPrOCedUreCSF is sent to the pathology department for analysis.
● NURSING ACTIONS: Monitor the puncture site. The client should remain lying for several hours to ensure that the site clots and to decrease the risk of a post-lumbar puncture headache, caused by CSF leakage.
● CLIENT EDUCATION: Normal activities may be resumed after prescribed bed rest is complete as long as in stable condition.
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 3 NeUrOLOGiC diAGNOsTiC PrOCedUres 21
COMPLICATIONSIf clotting does not occur to seal the dura puncture site, CSF can leak, resulting in a headache and increasing the potential for infection.
NURSING ACTIONS ● Encourage the client to lie flat in bed. Provide fluids for
hydration, and administer pain medication. ● Prepare the client for an epidural blood patch to seal the
hole in the dura if the headache persists.
Magnetic resonance imaging scan
An MRI scan of the head provides cross-sectional images of the cranial cavity. A contrast medium may be used to enhance the images.
● Unlike CT scans, MRI images are obtained using magnets, thus the consequences associated with radiation are avoided. This makes this procedure safer for women who are pregnant.
● The use of magnets precludes the ability to scan a client who has an artificial device (pacemakers, surgical clips, intravenous access port).
! Use Mri‑approved equipment to monitor vital signs and provide ventilator/oxygen assistance to clients undergoing Mri scans.
INDICATIONS ● MRI scans are used to detect abnormalities, monitor
response to treatment, and guide needles used for biopsies.
● MRIs are capable of discriminating soft tissue from tumor or bone. This makes the MRI scan effective in determining tumor size and blood vessel location.
CONSIDERATIONS
PrePrOCedUreNURSING ACTIONS
● Remove any transdermal patches with a foil backing, as these can cause burn injuries.
● Ensure that the client’s jewelry is removed prior to this procedure. The client should wear a hospital gown to prevent any metals from interfering with the magnet.
● If sedation is expected, the client should refrain from food or fluids for 4 to 8 hr prior to the procedure.
● Determine if the client has a history of claustrophobia, and explain the tight space and noise.
● Ask the client about any implants containing metal (pacemaker, orthopedic joints, artificial heart valves, intrauterine devices, aneurysm clips).
● Ensure all people who will be in the scanning area while the magnet is on remove all jewelry, electronics, and phones to prevent damage to themselves or the magnet.
● Place pillows in the small of the client’s back to prevent back pain from lying supine. The head must be secured to prevent unnecessary movement during the procedure.
iNTrAPrOCedUre ● Ensure the client remains supine with the
head stabilized. ● MRI scanning is noisy, and earplugs or sedation may
be provided.
POsTPrOCedUreNURSING ACTIONS
● If contrast media is injected, monitor the site to ensure that clotting has occurred and monitor for any indications of an allergic reaction.
● If sedation is administered, monitor the client until stable.
3.1 Lumbar puncture positioning
3.2 Lumbar puncture
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PET and SPECT scansPositron emission tomography and single-photon emission computed tomography scans are nuclear medicine procedures that produce three-dimensional images of the head. These images can be static (depicting vessels) or functional (depicting brain activity).
● A glucose-based tracer is injected into the blood stream prior to the PET scan. This initiates regional metabolic activity, which is then documented by the PET scanner. A radioisotope is used for SPECT scanning.
● A CT scan may be performed after a PET/SPECT scan, as this provides information regarding brain activity and pathological location (brain injury, death, neoplasm).
INDICATIONSA PET/SPECT scan captures regional metabolic processes, which is most useful in determining tumor activity and/or response to treatment. PET/SPECT scans are also able to determine the presence of dementia, indicated by the inability of the brain to respond to the tracer.
CONSIDERATIONS
PrePrOCedUrePET/SPECT scans use radiation, thus the risks and benefits to a client who might be pregnant must be discussed.
NURSING ACTIONS: Assess for a history of diabetes mellitus. While this condition does not preclude a PET/SPECT scan, alterations in the client’s medications can be necessary to avoid hyperglycemia or hypoglycemia before and after this procedure.
iNTrAPrOCedUre ● While the pictures are being obtained, the client must
lie flat with the head restrained. ● This procedure is not painful and sedation is
rarely necessary.
POsTPrOCedUreNURSING ACTIONS
● If radioisotopes are used, assess for allergic reaction. ● There is no follow-up care after a PET/SPECT scan. ● Because the tracer is glucose-based and short-acting
(less than 2 hr), it is broken down within the body as a sugar, not excreted.
Radiography (x‑ray) ● An x-ray uses electromagnetic radiation to capture
images of the internal structures of an individual. ● A structure’s image is light or dark relative to the
amount of radiation the tissue absorbs. The image is recorded on a radiograph, which is a black-and-white image that is held up to light for visualization. Some are recorded digitally and available immediately.
INDICATIONSX-ray examinations of the skull and spine can reveal fractures, curvatures, bone erosion and dislocation, and possible soft tissue calcification, all of which can damage the nervous system.
CONSIDERATIONS
PrePrOCedUreNURSING ACTIONS
● There is no specific preprocedure protocol for x-rays that do not use contrast. X-rays are often the first diagnostic tool used after an injury (such as rule out cervical fracture in head trauma).
● Determine whether the client is pregnant. ● Ensure that the client’s jewelry is removed and that no
clothes cover the area.CLIENT EDUCATION: Explain that the amount of radiation used in contemporary x-ray machines is very small.
iNTrAPrOCedUreThe procedure is quick, but the client is to remain still during the procedure.
POsTPrOCedUreNURSING ACTIONS: No postprocedure care is required.
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 3 NeUrOLOGiC diAGNOsTiC PrOCedUres 23
Application Exercises
1. A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (select all that apply.)
A. Use the Glasgow Coma scale when assessing the client.
B. Assist the client to a supine position.
C. Administer an opioid medication.
d. encourage the client to increase fluid intake.
e. instruct the client to perform deep breathing and coughing exercises.
2. A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for iCP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy?
A. Headache
B. infection
C. Aphasia
d. Hypertension
3. A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma scale (GCs). The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCs scores should the nurse document?
A. e2 + V3 + M5 = 10
B. e3 + V4 + M4 = 11
C. e4 + V5 + M6 = 15
d. e2 + V2 + M4 = 8
4. A nurse is developing a plan of care for a client who is scheduled for cerebral angiography with contrast media. Which of the following statements by the client should the nurse report to the provider? (select all that apply.)
A. “i think i might be pregnant.”
B. “i take warfarin.”
C. “i take antihypertensive medication.”
d. “i am allergic to shrimp.”
e. “i ate a light breakfast this morning.”
5. A nurse is providing education to a client who is to undergo an electroencephalogram (eeG) the next day. Which of the following information should the nurse include in the teaching?
A. “do not wash your hair the morning of the procedure.”
B. “Try to stay awake most of the night prior to the procedure.”
C. “The procedure will take approximately 15 minutes.”
d. “you will need to lie flat for 4 hours after the procedure.”
Active Learning Scenario
A nurse is developing a plan of care for a client who is scheduled for a magnetic resonance imaging (Mri) scan with contrast media. What should the nurse include in the plan of care? Use the ATi Active Learning Template: diagnostic Procedure to complete this item.
PROCEDURE NAME: define this diagnostic test.
NURSING INTERVENTIONS (PRE, INTRA, POST): identify three preprocedure actions, one intraprocedure action, and one postprocedure action.
24 CHAPTER 3 NeUrOLOGiC diAGNOsTiC PrOCedUres CONTENT MASTERY SERIES
Application Exercises Key
1. A. The Glasgow Coma scale is used to assess a client’s level of consciousness and is not necessary following a lumbar puncture.
B. CORRECT: The nurse should assist the client to a supine position, which can relieve a headache following a lumbar puncture.
C. CORRECT: The nurse should administer an opioid medication for a client’s report of headache pain.
d. CORRECT: The nurse should encourage an increased fluid intake to maintain a positive fluid balance, which can relieve a headache following a lumbar puncture.
e. Coughing can increase iCP, which can result in an increase in the client’s headache.
NCLEX® Connection: Reduction of Risk Potential, Potential for Complications of Diagnostic Tests/Treatments/Procedures
2. A. The nurse should monitor a client who has increased iCP for a headache, but a headache does not indicate a complication directly related to the ventriculostomy.
B. CORRECT: The nurse should monitor a client who has a ventriculostomy for infection, which is a complication. The nurse should use strict asepsis to avoid this life‑threatening condition, which can result in meningitis.
C. The nurse should monitor a client who has increased iCP for aphasia related to the head injury, but this not a complication directly related to the ventriculostomy.
d. The nurse should monitor a client who has increased iCP for hypertension, but this is not a complication directly related to the ventriculostomy.
NCLEX® Connection: Reduction of Risk Potential, Potential for Complications of Diagnostic Tests/Treatments/Procedures
3. A. The calculation is incorrect. e2 represents eyes opening secondary to pain, V3 represents verbal response with words spoken inappropriately, and M5 represents motor response to pain with a local reaction.
B. CORRECT: The client’s score is calculated correctly, indicating moderate head injury. e3 represents opening eyes secondary to voice stimulation, V4 represents verbal conversation that is incoherent and disoriented, and M4 represents motor response as a general withdrawal to pain.
C. The client’s score is calculated incorrectly. e4 represents eyes opening spontaneously, V5 represents verbal conversation as coherent and oriented, and M6 indicates a client is able to follow commands.
d. The client’s score is calculated incorrectly. e2 represents eyes opening secondary to pain, V2 represents verbal response by the client making sounds but speaking no words, and M4 is a motor response with a general withdrawal to pain.
NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests
4. A. CORRECT: The nurse should report the client’s statement of possible pregnancy to the provider because the contrast media can place the fetus at risk.
B. CORRECT: The nurse should report that the client is taking warfarin to the provider due to the potential for bleeding following angiography.
C. There is no contraindication related to cerebral angiography for a client who is taking antihypertensive medication.
d. CORRECT: The nurse should report a client’s report of allergy to shrimp, which is a shellfish, to the provider due to a potential allergic reaction to the contrast media.
e. CORRECT: The nurse should report a client’s intake of food to the provider since the client should remain NPO for 4 to 6 hr prior to the procedure.
NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests
5. A. The nurse should teach the client to wash her hair on the morning of the procedure to remove oils, gels, and sprays, which can affect the eeG readings.
B. CORRECT: The nurse should teach the client to remain awake most of the night to provide cranial stress and increase the possibility of abnormal electrical activity.
C. The nurse should teach the client that the procedure will take approximately 1 hr.
d. The nurse should teach the client that normal activity can resume immediately following the procedure.
NCLEX® Connection: Reduction of Risk Potential, Therapeutic Procedures
Active Learning Scenario Key
Using the ATI Active Learning Template: Diagnostic Procedure
PROCEDURE NAME: Magnetic resonance imaging (Mri) scan relies on magnetic field to take multiple images of the body.
NURSING INTERVENTIONS (PRE, INTRA, POST) ● Preprocedure
◯ remove all client jewelry. ◯ determine if the client has claustrophobia. ◯ Question the client concerning implants containing metal. ◯ Question the client regarding allergies.
● intraprocedure: stabilize the client’s head ● Postprocedure: Monitor for allergic reaction to the contrast media used during the Mri.
NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 4 PAiN MANAGeMeNT 25
UNIT 2 NEUROLOGIC DISORDERSSECTION: DIAGNOSTIC AND THERAPEUTIC PROCEDURES
CHAPTER 4 Pain Managementeffective pain management includes the use of pharmacological and nonpharmacological pain management therapies.
Clients have a right to adequate assessment and management of pain. Nurses are accountable for the assessment of pain. Professional organizations and The Joint Commission have mandates requiring pain assessment and management. The nurse’s role is that of an advocate, member of the health care team, and educator for effective pain management.
Nurses have a priority responsibility for the continual assessment of the client’s pain level and to provide individualized interventions. depending on the setting and route of analgesia administration, the nurse might need to reassess pain 10 to 60 min after administering medication.
Assessment challenges can occur with clients who have cognitive impairment, who speak a different language than the nurse, or who receive prescribed mechanical ventilation.
PHYSIOLOGY ● Nociceptive pain involves transduction, transmission,
perception, and modulation of impulses generated by nociceptors located throughout the body.
● Stimuli following tissue damage from cuts, burns, tumor growth, or chemicals trigger these nociceptors to send a message to the nervous system.
● Neuropathic pain is caused by changes in the peripheral or central nervous system.
◯ Peripheral sensitization, changes in ion channels, and neuroplasticity are peripheral nervous system changes that contribute to neuropathic pain. Neuroplasticity occurs when nerve endings are damaged and reorganized in an abnormal manner.
◯ Central nervous system changes that lead to neuropathic pain include an increase in the excitability of central neurons, an increase in the release of and binding of neurotransmitters, and reorganization of nerves following injury, all of which alter or increase pain sensations.
ASSESSMENTPain is whatever the person experiencing it says it is, and it exists whenever the person says it does. The client’s report of pain is the most reliable diagnostic measure of pain. Self-report using standardized pain scales is useful for clients over the age of 7 years. Specialized pain scales are available for use with younger children and other clients who are unable to self-report pain. There are a variety of pain scales that feature images, numbers, intensity indicators, and descriptive words, and in various languages.
● Assess and document pain (the fifth vital sign) according to the client’s condition and agency guidelines. (4.1)
● Use a focused assessment to obtain subjective data. (4.2)
CHAPTER 4
4.1 Pain categories
Acute painAcute pain is protective, temporary, usually self‑limiting, and resolves with tissue healing.Physiological responses (sympathetic nervous system) are fight‑or‑flight responses (tachycardia, hypertension, anxiety, diaphoresis, muscle tension).Behavioral responses include grimacing, moaning, flinching, and guarding.The nurse should be aware that a client not exhibiting physiological or behavioral responses does not mean that pain is absent. interventions include treatment of the underlying problem.surgical incisions and wounds from injury produce acute pain.
Chronic painChronic pain is not protective. it is ongoing or recurs frequently, lasting longer than 3 months and persisting beyond tissue healing.Physiological responses do not usually increase vital signs. The client’s vital signs can actually be lower than normal in response to chronic pain. Clients can have depression, fatigue, decreased level of functioning, or disability. Chronic pain might not have a known cause, and it might not respond to interventions.Chronic pain can be classified as chronic cancer pain or chronic noncancer pain.The pain associated with osteoarthritis and neuropathy are examples of chronic pain.
Nociceptive painNociceptive pain arises from damage to or inflammation of tissue other than that of the peripheral and central nervous systems.Nociceptive pain is the result of activation of normal processing of painful stimuli.it is usually throbbing, aching, and localized.This pain is managed using opioids and non‑opioid medications.
TYPES OF NOCICEPTIVE PAINsomatic: in bones, joints, muscles, skin, or connective tissues. Visceral: in internal organs such as the stomach or intestines. it can cause referred pain in other body locations separate from the stimulus.
Neuropathic painNeuropathic pain arises from abnormal or damaged pain nerves. it differs from nociceptive pain as it is the abnormal processing of painful stimuli.it includes phantom limb pain, pain below the level of a spinal cord injury, and diabetic neuropathy.Neuropathic pain is usually intense, shooting, burning, or described as “pins and needles.”This pain typically is managed using adjuvant medications (antidepressants, antispasmodic agents, skeletal muscle relaxants).
26 CHAPTER 4 PAiN MANAGeMeNT CONTENT MASTERY SERIES
TyPes OF PAiNPain is categorized by duration (acute or chronic) or by pathology (nociceptive or neuropathic).
● Clients can experience mixed pain that is difficult to categorize. Conditions that cause mixed pain include fibromyalgia, HIV, and Lyme disease.
● Breakthrough pain occurs when a client experiences an exacerbation of acute pain. Clients who have chronic conditions can experience episodes of breakthrough pain requiring additional pain relief measures.
risK FACTOrsRisk factors for undertreatment of pain
● Cultural and societal attitudes ● Lack of knowledge ● Fear of addiction ● Exaggerated fear of respiratory depression
Populations at risk for undertreatment of pain ● Infants ● Children ● Older adults ● Clients who have substance use disorder
Causes of acute and chronic pain ● Trauma ● Surgery ● Cancer (tumor invasion, nerve compression, bone
metastases, associated infections, immobility) ● Arthritis ● Fibromyalgia ● Neuropathy ● Diagnostic or treatment procedures (injection,
intubation, radiation)
Factors that affect the pain experience ● Age
◯ Infants cannot verbalize or understand their pain. ◯ Older adult clients can have multiple pathologies that cause pain and limit function.
● Fatigue can increase sensitivity to pain. ● Genetic sensitivity can increase or decrease
pain tolerance. ● Cognitive function: Clients who are cognitively impaired
might not be able to report pain or report it accurately. ● Prior experiences can increase or decrease sensitivity
depending on whether clients obtained adequate relief. ● Anxiety and fear can increase sensitivity to pain. ● Support systems can decrease sensitivity to pain. ● Culture can influence how clients express pain or the
meaning they give to pain.
4.2 Focused pain assessment
LocationUSE ANATOMICAL TERMINOLOGY AND LANDMARKS TO DESCRIBE LOCATION.Ask: “Where is your pain?”Ask: “Does it radiate anywhere else?” Ask clients to point to the location.
QualityQUALITY REFERS TO HOW THE PAIN FEELS: sharp, dull, aching, burning, stabbing, pounding, throbbing, shooting, gnawing, tender, heavy, tight, tiring, exhausting, sickening, terrifying, torturing, nagging, annoying, intense, or unbearable.Ask: “What does the pain feel like?” Give more than two choices (“Is the pain throbbing, burning, or stabbing?”).
MeasuresINTENSITY, STRENGTH, AND SEVERITY ARE “MEASURES” OF THE PAIN. Use visual analog scales (description scale, number rating scale) to measure pain, monitor pain, and evaluate the effectiveness of interventions.Ask: “How much pain do you have now?”Ask: “What is the worst/best the pain has been?”Ask: “Rate your pain on a scale of 0 to 10.”
TimingONSET, DURATION, FREQUENCY.Ask: “When did it start?”Ask: “How long does it last?”Ask: “How often does it occur?”Ask: “Is it constant or intermittent?”
SettingHOW THE PAIN AFFECTS DAILY LIFE OR HOW ACTIVITIES OF DAILY LIVING (ADLS) AFFECT THE PAIN.Ask: “Where are you when the symptoms occur?”Ask: “What are you doing when the symptoms occur?”Ask: “How does the pain affect your sleep?”Ask: “How does the pain affect your ability to work and do your job?”
Associated manifestationsDOCUMENT ASSOCIATED MANIFESTATIONS: fatigue, depression, nausea, anxiety.Ask: “What other symptoms do you have when you are feeling pain?”
Aggravating/relieving factorsAsk: “What makes the pain better?”Ask: “What makes the pain worse?”Ask: “Are you currently taking any prescription, herbal, or over‑the‑counter medications?”
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 4 PAiN MANAGeMeNT 27
eXPeCTed FiNdiNGs ● Behaviors complement self-report and assist in pain
assessment of nonverbal clients. ◯ Facial expressions (grimacing, wrinkled forehead),
body movements (restlessness, pacing, guarding) ◯ Moaning, crying ◯ Decreased attention span
● Blood pressure, pulse, and respiratory rate can temporarily increase with acute pain. Eventually, increases in vital signs will stabilize despite the persistence of pain. Therefore, physiologic indicators might not be an accurate measure of pain over time.
PATIENT‑CENTERED CARE
NUrsiNG CAre ● Incorporate pharmacological and nonpharmacological
strategies into the plan of care. Consider the client’s preferences. Discuss the use of complementary and alternative practices.
● Assist the client to set a pain-relief or comfort-function goal and refer back to the goal when planning or evaluating pain interventions.
● Determine the client’s need for scheduled analgesia, such as for chronic or postoperative pain.
● Plan to premedicate the client prior to painful procedures (repositioning, wound care, invasive diagnostic testing).
● Refer to dosage charts that describe equianalgesia to compare the potency levels of various pain medications.
NONPHArMACOLOGiCAL PAiN MANAGeMeNT
● Nonpharmacological pain strategies help to improve coping by relieving stress associated with pain. These strategies can assist clients in reducing the amount of pharmacological interventions for pain and are particularly helpful when clients cannot take pain medication.
● Clients might choose nonpharmacological complementary and alternative measures to manage pain.
◯ Mind-body practices (yoga, chiropractic manipulation)
◯ Cognitive approaches (meditation, distraction) ◯ Natural products (herbs, oils)
PHArMACOLOGiCAL iNTerVeNTiONsAnalgesics are the mainstay for relieving pain. The parenteral route is best for immediate, short-term relief of acute pain. The oral route is better for chronic, nonfluctuating pain.
● Treatment tools, such as the WHO analgesic ladder, suggest administering non-opioid analgesics first, progressing through weak opioids to stronger ones to manage pain.
● Expect to administer IV analgesia immediately postoperatively, and to transition clients to oral medication as pain is managed properly through the postoperative period.
● When transitioning clients from IV to oral analgesia, a larger dose is required for oral dosing because the full dose of medication does not reach the bloodstream.
● Clients experiencing acute pain receive doses that are gradually titrated down until they can be comfortable without medication, or at a minimal dose.
● The three classes of analgesics are non-opioids, opioids, and adjuvants.
Non-opioid analgesicsNon-opioid analgesics are appropriate for treating mild to moderate pain, and are often added to opioids for treatment for more intense pain. Non-opioid analgesics also have antipyretic and anti-inflammatory properties.
● Non-opioid analgesics are often prescribed following painful procedures.
● Acetaminophen is most often used, alone or in combination with other mediations.
◯ Ensure the total amount of acetaminophen a client consumes daily does not exceed 4 g for clients 50 kg (110 lb) or greater.
◯ It is safe to administer acetaminophen concurrently with NSAIDS (ibuprofen, aspirin, celecoxib, naproxen) ketorolac, because the medications act in different ways.
28 CHAPTER 4 PAiN MANAGeMeNT CONTENT MASTERY SERIES
Opioid analgesicsOpioid analgesics are appropriate for treating moderate to severe pain. The term “narcotic” is not synonymous with opioid analgesics. Narcotics can also refer to illegal substances such as cocaine.
● Opioid analgesics for moderate pain include tramadol, hydrocodone, and codeine.
● Hydromorphone, fentanyl, morphine, oxycodone, or methadone are effects for more severe pain. Morphine is the opioid most used and other opioid effects are compared to the effects of morphine.
● Meperidine is no longer recommended for use except in rare conditions at low doses.
● Check opioid formulations carefully to determine whether a short-acting or modified release (extended release) dose is indicated.
● For many opioids, the dose can be titrated upward progressively until the client experiences pain relief; however, upward titration increases the risk for adverse effects.
● Opioids are available in transdermal, transmucosal, and buccal routes.
● It is essential to monitor and intervene for adverse effects of opioid use.
◯ Constipation: Use a preventative approach (monitoring of bowel movements, fluids, fiber intake, exercise, stool softeners, stimulant laxatives, enemas).
◯ Orthostatic hypotension: Advise clients to sit or lie down if lightheadedness or dizziness occur. Instruct clients to avoid sudden changes in position by slowly moving from a lying to a sitting or standing position. Provide assistance with ambulation.
◯ Urinary retention: Monitor I&O, assess for distention, administer bethanechol, and catheterize.
◯ Nausea/vomiting: Administer antiemetics, advise clients to lie still and move slowly, and eliminate odors.
◯ Sedation: Monitor level of consciousness and take safety precautions. Sedation usually precedes respiratory depression.
◯ Respiratory depression: Monitor respiratory rate prior to and following administration of opioids. Initial treatment of respiratory depression and sedation is generally a reduction in opioid dose. If necessary, administer naloxone to reverse opioid effects.
Adjuvant analgesicsAdjuvant analgesics, or coanalgesics, enhance the effects of non-opioids, help alleviate other manifestations that aggravate pain (depression, seizures, inflammation), and are useful for treating neuropathic pain.
● Adjuvant medications include the following. ◯ Anticonvulsants: carbamazepine ◯ Antianxiety agents: diazepam ◯ Tricyclic antidepressants: amitriptyline ◯ Antihistamine: hydroxyzine ◯ Glucocorticoids: dexamethasone ◯ Antiemetics: ondansetron ◯ Anesthetics: Ketamine
Patient-controlled analgesia (PCA)PCA is a medication delivery system that allows clients to self-administer safe doses of opioids.
● Small, frequent dosing ensures consistent plasma levels. ● Clients have less lag time between identified need and
delivery of medication, which increases their sense of control and can decrease the amount of medication they need.
● Morphine and hydromorphone are typical opioids for PCA delivery.
● Clients should let the nurse know if using the pump does not control the pain.
● To prevent inadvertent overdosing, the client is the only person who should push the PCA button.
Other pain management strategies ● Implantable pain pumps ● Medication injections and short-term infusions
◯ Local infusion into a wound ◯ Regional infusion to block a group of nerves (epidural infusions)
● Stimulation of the brain and spinal cord ● Nerve ablation and cryoablation procedures
Chronic pain interventions ● Strategies specific for relieving chronic pain include the
above interventions, plus: ◯ Administering long-acting or controlled-release opioid analgesics (including the transdermal route).
◯ Administering analgesics around the clock rather than PRN.
◯ Referral to accredited pain management center, which offer a holistic approach to pain management.
◯ Referral to palliative or hospice treatment centers as indicated, based on the case of pain.
COMPLICATIONS ● Undertreatment of pain is a serious complication and
can lead to increased anxiety with acute pain and depression with chronic pain. Assess clients for pain frequently, and intervene as appropriate.
● Sedation, respiratory depression, and coma can occur as a result of overdosing. Sedation always precedes respiratory depression.
◯ Identify high-risk clients (older adult clients). ◯ Carefully titrate doses while closely monitoring respiratory status.
◯ Stop the opioid and give the antagonist naloxone if respiratory rate is below 8/min and shallow, or the client is difficult to arouse.
◯ The nurse should closely monitor the client following administration of naloxone. The duration of the certain opioids can last longer than the effectiveness of the naloxone creating a need for additional doses.
◯ Identify the cause of sedation. ◯ Use a sedation scale in addition to a pain rating scale to assess pain, especially when administering opioids.
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 4 PAiN MANAGeMeNT 29
Application Exercises
1. A nurse is caring for a client who is experiencing mild acute pain after spraining an ankle. Which of the following analgesics should the nurse expect to administer?
A. Ketorolac
B. Ketamine
C. Meperidine
d. Methadone
2. A nurse at a clinic is talking with a client who has cancer and takes extended‑release opioids twice daily. The client reports an increase in localized, achy pain over the last few days. How should the nurse document this increase in pain?
A. Phantom limb pain
B. Mixed pain
C. Breakthrough pain
d. Neuropathic pain
3. A nurse is caring for a client who is receiving morphine via a patient‑controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following client statements indicates that the client understands how to use the device?
A. “i’ll wait to use the device until it’s absolutely necessary.”
B. “i’ll be careful about pushing the button so i don’t get an overdose.”
C. “i should tell the nurse if the pain doesn’t stop after i use this device.”
d. “i will ask my son to push the dose button when i am sleeping.”
4. A nurse is discussing pain assessment with a newly licensed nurse. Which of the following information should the nurse include?
A. Most clients exaggerate their level of pain.
B. Pain must have an identifiable source to justify the use of opioids.
C. Objective data are essential in assessing pain.
d. Pain is whatever the client says it is.
5. A nurse is monitoring a client who is receiving opioid analgesia. Which of the following findings should the nurse identify as adverse effects of opioid analgesics? (select all that apply.)
A. Urinary incontinence
B. diarrhea
C. Bradypnea
d. Orthostatic hypotension
e. Nausea
Active Learning Scenario
A nurse on a medical‑surgical unit is reviewing with a group of newly licensed nurses the various types of pain the clients on the unit have. Use the ATi Active Learning Template: Basic Concept to complete this item.
UNDERLYING PRINCIPLES: List the four different types of pain, their definitions, and characteristics.
30 CHAPTER 4 PAiN MANAGeMeNT CONTENT MASTERY SERIES
Active Learning Scenario Key
Using the ATI Active Learning Template: Basic Concept
UNDERLYING PRINCIPLES
Acute pain ● definition: Protective, temporary, usually self‑limiting, resolves with tissue healing
● Physiological responses: Tachycardia, hypertension, anxiety, diaphoresis, muscle tension
● Behavioral responses: Grimacing, moaning, flinching, guarding
Chronic pain ● definition: Not protective; ongoing or recurs frequently, lasts longer than 3 months, persists beyond tissue healing, can be chronic cancer pain or chronic noncancer pain
● Physiological responses: No change in vital signs, depression, fatigue, decreased level of functioning, disability
Nociceptive pain ● definition: Arises from damage to or inflammation of tissue other than that of the peripheral and central nervous systems, is usually throbbing, aching, localized; pain typically responds to opioids and non‑opioid medications
● Types of nociceptive pain ◯ somatic: in bones, joints, muscles, skin, or connective tissues ◯ Visceral: in internal organs such as the stomach or intestines, can cause referred pain
Neuropathic pain ● definition: Arises from abnormal or damaged pain nerves (phantom limb pain, pain below the level of a spinal cord injury, diabetic neuropathy), usually intense, shooting, burning, or “pins and needles”
● Physiological responses to adjuvant medications (antidepressants, antispasmodic agents, skeletal muscle relaxants)
NCLEX® Connection: Pharmacological and Parenteral Therapies, Pharmacological Pain Management
Application Exercises Key
1. A. CORRECT: Ketorolac is in the NsAid category and is useful for anti‑inflammatory effects in managing minor pain following a sprain.
B. Ketamine is an anesthetic agent that is often used as an adjuvant medication for treating neuropathic pain.
C. Meperidine is not recommended for regular use due to adverse effects of the medication.
d. Methadone is effective for treating severe pain.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Pharmacological Pain Management
2. A. Phantom limb pain is pain that is perceived to be initiated from a part of the body that is no longer present.
B. Mixed pain is pain that is difficult to define, for conditions such as fibromyalgia.
C. CORRECT: Breakthrough pain is an acute exacerbation of pain beyond the level the client typically experiences.
d. Neuropathic pain sensations are described as burning, shooting, or pins and needles.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Pharmacological Pain Management
3. A. The client may use the device when he begins to feel pain. it will help prevent unnecessary worsening of the pain and more doses of analgesia to provide relief.
B. A feature of PCA devices is the timing control or lockout mechanism, which enforces a preset minimum interval between medication doses. This safety feature is one means of preventing an overdose because the client cannot self‑administer another dose of medication until that time interval has passed.
C. CORRECT: The nurse should identify that PCA is a method of delivering pain medication through an electronic infusion device that allows the client to self‑administer pain medication on an as‑needed basis. if the client is not achieving adequate pain control, he should let the nurse know so that she can initiate a reevaluation of the client’s pain management plan.
d. The client is the only one who should operate the PCA pump. in situations where the client is not able to do so, the provider may authorize a nurse or a family member to operate the pump.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Pharmacological Pain Management
4. A. A misconception about pain is that clients exaggerate their pain level.
B. Clients can have pain without being able to identify the source.
C. Objective data are not always present when clients have pain.
d. CORRECT: The nurse should identify that pain is a subjective experience, and the client is the best source of information about it.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Pharmacological Pain Management
5. A. Urinary retention, not urinary incontinence, is a common adverse effect of opioid analgesia.
B. Constipation, not diarrhea, is a common adverse effect of opioid analgesia.
C. CORRECT: respiratory depression, which causes respiratory rates to drop to dangerously low levels, is a common adverse effect of opioid analgesia.
d. CORRECT: dizziness or lightheadedness when changing positions is a common adverse effect of opioid analgesia.
e. CORRECT: Nausea and vomiting are common adverse effects of opioid analgesia.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Expected Actions/Outcomes
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 5 MeNiNGiTis 31
UNIT 2 NEUROLOGIC DISORDERSSECTION: CENTRAL NERVOUS SYSTEM DISORDERS
CHAPTER 5 MeningitisMeningitis is an inflammation of the meninges, which are the membranes that protect the brain and spinal cord.
Viral, or aseptic, meningitis is the most common form of meningitis and commonly resolves without treatment. Fungal meningitis is common in clients who have Aids. Bacterial (or septic) meningitis is a contagious infection with a high mortality rate. The prognosis depends on how quickly care is initiated.
There are three vaccines for different pathogens that cause bacterial meningitis. One is available for high‑risk populations, such as residential college students.
HEALTH PROMOTION AND DISEASE PREVENTION
Haemophilus influenzae type b (Hib) vaccineEnsure infants receive vaccine for bacterial meningitis on schedule. A series of four doses is recommended beginning at 2 months of age, with the final dose at 12 to 15 months.
Pneumococcal polysaccharide vaccine (PPSV)Though primarily intended to prevent respiratory infection, this immunization also decreases the risk for CNS infections. Vaccinate adults who are immunocompromised, have a chronic disease, smoke cigarettes, or live in a long-term care facility. Follow CDC guidelines for reimmunization. Give one dose to adults older than 65 who have not previously been immunized nor have history of disease.
Meningococcal vaccine (MCV4) (Neisseria meningitidis)Ensure that adolescents receive the vaccine on schedule and prior to living in a residential setting in college. Individuals in other communal living conditions (such as military) also should be immunized. An initial dose is recommended for healthy children between the ages of 11 to 12, with a booster administered at age 16.
ASSESSMENT
risK FACTOrsViral meningitis
● Viral illnesses (mumps, measles, herpes, arboviruses [West Nile]).
● There is no vaccine against viral meningitis.
Fungal meningitis: Fulminant fungal-based infection of the sinuses are from the organism Cryptococcus neoformans.
Bacterial meningitis: Bacterial-based infections (otitis media, pneumonia, sinusitis) in which the infectious micro-organism is Neisseria meningitidis, Streptococcus pneumoniae, or Haemophilus influenzae.
Immunosuppression
Direct contamination of spinal fluid
Invasive procedures, skull fracture, or penetrating wound
Environment: Overcrowded living conditions.
eXPeCTed FiNdiNGsSUBJECTIVE DATA
● Excruciating, constant headache ● Nuchal rigidity (stiff neck) ● Photophobia (sensitivity to light)
OBJECTIVE DATA: Physical Assessment Findings ● Fever and chills ● Nausea and vomiting ● Altered level of consciousness (confusion, disorientation,
lethargy, difficulty arousing, coma) ● Positive Kernig’s sign (resistance and pain with
extension of the client’s leg from a flexed position) ● Positive Brudzinski’s sign (flexion of the knees and hips
occurring with deliberate flexion of the client’s neck) ● Hyperactive deep tendon reflexes ● Tachycardia ● Seizures ● Red macular rash (meningococcal meningitis) ● Restlessness, irritability
LABOrATOry TesTs ● Urine, throat, nose, and blood culture and sensitivity:
Culture and sensitivity of various body fluids identify possible infectious bacteria and an appropriate broad-spectrum antibiotic. Not definitive for meningitis but can guide initial selection of antimicrobial.
● CBC: Elevated WBC count
CHAPTER 5
32 CHAPTER 5 MeNiNGiTis CONTENT MASTERY SERIES
diAGNOsTiC PrOCedUresCerebrospinal fluid (CSF) analysis
● CSF analysis is the most definitive diagnostic procedure. CSF is collected during a lumbar puncture performed by the provider.
● Results indicative of meningitis ◯ Appearance of CSF: cloudy (bacterial) or clear (viral) ◯ Elevated WBC ◯ Elevated protein ◯ Decreased glucose (bacterial) ◯ Elevated CSF pressure
● Counterimmunoelectrophoresis (CIE) can be done on CSF to determine whether the infectious agent is viral or protozoa. This diagnostic study is also indicated if the client received antibiotics before CSF was collected.
CT scan and MRI: A CT scan or an MRI can be performed to identify increased intracranial pressure (ICP) and/or an abscess.
PATIENT‑CENTERED CARE
NUrsiNG CAre ● Isolate the client as soon as meningitis is suspected. ● Maintain isolation precautions per hospital policy.
◯ Initiate droplet precautions, which require a private room. Continue droplet precautions until antibiotics have been administered for 24 hr and oral and nasal secretions are no longer infectious. Clients who have bacterial meningitis might need to remain on droplet precautions continuously.
◯ Standard precautions are implemented for all clients who have meningitis.
● Implement fever-reduction measures, such as a cooling blanket, if necessary.
● Report meningococcal infections to the public health department.
● Decrease environmental stimuli. ● Provide a quiet environment. ● Minimize exposure to bright light (natural and electric). ● Maintain bed rest with the head of the bed
elevated to 30°. ● Monitor for increased ICP. ● Tell the client to avoid coughing and sneezing, which
increase ICP. ● Maintain client safety, such as seizure precautions. ● Replace fluid and electrolytes as indicated by
laboratory values. ● Older adult clients are at an increased risk for secondary
complications, such as pneumonia. ● Monitor vital signs to assess for septic shock.
MediCATiONs ● Ceftriaxone or cefotaxime in combination with
vancomycin: Antibiotics given until culture and sensitivity results are available. Effective for bacterial infections.
● Phenytoin: Anticonvulsants given if ICP increases or client experiences a seizure.
● Acetaminophen, ibuprofen: Analgesics for headache and/or fever. Non-opioid to avoid masking changes in the level of consciousness.
● Ciprofloxacin, rifampin, or ceftriaxone: Prophylactic antibiotics given to individuals in close contact with the client.
COMPLICATIONS
Increased ICP
Meningitis can cause ICP to increase, possibly to the point of brain herniation.
NURSING ACTIONS ● Monitor for indications of increasing ICP (decreased
level of consciousness, pupillary changes, impaired extraocular movements).
● Provide interventions to reduce ICP (positioning with head of the bed elevation at 30° and avoidance of coughing and straining).
● Mannitol can be administered via IV.
SIADH
SIADH can be a complication of meningitis due to abnormal stimulation to the hypothalamic area of the brain, causing excess secretion of antidiuretic hormone (vasopressin).
NURSING ACTIONS ● Monitor for manifestations (dilute blood,
concentrated urine). ● Provide interventions, such as the administration of
demeclocycline and restriction of fluid. ● Monitor the client’s weight daily.
Septic emboli ● Septic emboli can form during meningitis and travel to
other parts of the body, particularly the hands, but can occur in the feet as well.
● Development of gangrene can necessitate an amputation. ● Septic emboli can lead to disseminated intravascular
coagulation or stroke.
NURSING ACTIONS ● Monitor circulatory status of extremities and
coagulation studies. ● Report any alterations immediately to the provider.
Online Image: Gangrenous Toe
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 5 MeNiNGiTis 33
Application Exercises
1. A nurse is assessing a client who reports severe headache and a stiff neck. The nurse’s assessment reveals positive Kernig’s and Brudzinski’s signs. Which of the following actions should the nurse perform first?
A. Administer antibiotics.
B. implement droplet precautions.
C. initiate iV access.
d. decrease bright lights.
2. A nurse is assessing for the presence of Brudzinski’s sign in a client who has suspected meningitis. Which of the following actions should the nurse take when performing this technique? (select all that apply.)
A. Place client in supine position.
B. Flex client’s hip and knee.
C. Place hands behind the client’s neck.
d. Bend client’s head toward chest.
e. straighten the client’s flexed leg at the knee.
3. A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure (iCP). Which of the following actions should the nurse plan to take? (select all that apply.)
A. implement seizure precautions.
B. Perform neurologic checks four times a day.
C. Administer morphine for the report of neck and generalized pain.
d. Turn off room lights and television.
e. Monitor for impaired extraocular movements.
F. encourage the client to cough frequently.
4. A nurse is reviewing the use of the meningococcal vaccine (MCV4) for the prevention of meningitis with a newly licensed nurse. Which of the following information should the nurse include?
A. The vaccine is indicated to reduce the risk of respiratory infection.
B. The vaccine is administered in a series of four doses.
C. The vaccine is recommended for adolescents before starting college.
d. The vaccine is initially given at 2 months of age.
5. A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? (select all that apply.)
A. Monitor for bradycardia.
B. Provide an emesis basin at the bedside.
C. Administer antipyretic medication.
d. Perform a skin assessment.
e. Keep the head of the bed flat.
Active Learning Scenario
A nurse is reviewing the plan of care for a client who has bacterial meningitis. Use the ATi Active Learning Template: system disorder to complete this item.
ALTERATION IN HEALTH (DIAGNOSIS): define bacterial meningitis.
MEDICATIONS: identify three medications, their actions, and the reason for administration.
COMPLICATIONS: describe two complications of meningitis.
34 CHAPTER 5 MeNiNGiTis CONTENT MASTERY SERIES
Application Exercises Key
1. A. The nurse should administer antibiotics to stop the micro‑organisms from multiplying, but this is not the priority action.
B. CORRECT: When using the urgent vs. nonurgent approach to care, the nurse determines the priority action is to initiate droplet precautions when meningitis is suspected to prevent spread of the disease to others.
C. The nurse should initiate iV access to allow iV medication and fluid administration, but this is not the priority action.
d. The nurse should decrease bright lights because of the client’s sensitivity to light, but this is not the priority action.
NCLEX® Connection: Safety and Infection Control, Standard Precautions/Transmission‑Based Precautions/Surgical Asepsis
2. A. CORRECT: The nurse should place the client in supine position when assessing for Brudzinski’s sign.
B. The nurse should flex the client’s hip and knee when assessing for Kernig’s sign.
C. CORRECT: The nurse should place her hands behind the client’s neck when assessing for Brudzinski’s sign, in order to flex the client’s neck.
d. CORRECT: The nurse should bend the client’s head toward the chest when assessing for Brudzinski’s sign.
e. The nurse should straighten the client’s flexed leg at the knee when assessing for Kernig’s sign.
NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests
3. A. CORRECT: The client is at risk for seizures due to possible increased iCP. Therefore, the nurse should implement seizure precautions to reduce the client’s risk for injury.
B. The nurse should perform neurologic checks at least every 2 hr for a client who is at risk for increased iCP.
C. The nurse should avoid administering opioids to a client who is at risk for increased iCP. Opioids can mask changes in the client’s level of consciousness.
d. CORRECT: The nurse should turn off room lights and the television because they can increase neuron stimulation and cause a seizure when a client is at risk for increased iCP.
e. CORRECT: The nurse should monitor for impaired extraocular movements because this finding can indicate increased iCP.
F. The nurse should instruct the client to avoid coughing because this action can cause increased iCP.
NCLEX® Connection: Physiological Adaptation, Alterations in Body Systems
4. A. The pneumococcal vaccine is primarily indicated to reduce the risk of respiratory infection. However, it also reduces the risk of CNs infection.
B. The HiB vaccine is administered to infants in a series of four doses.
C. CORRECT: The nurse should identify that the meningococcal vaccine is recommended for adolescents prior to starting college due to the increased risk for infection in communal living facilities.
d. The initial dose of the HiB vaccine is recommended for infants at 2 months of age.
NCLEX® Connection: Safety and Infection Control, Standard Precautions/Transmission‑Based Precautions/Surgical Asepsis
5. A. The nurse should plan to monitor for tachycardia when a client has meningitis.
B. CORRECT: The nurse should provide an emesis basin at the bedside because the client who has meningitis can have nausea and vomiting.
C. CORRECT: The nurse should plan to administer antipyretic medication for fever to a client who has meningitis.
d. CORRECT: The nurse should perform a skin assessment to determine whether the client has a red macular rash associated with meningococcal meningitis.
e. The nurse should elevate the head of the client’s bed 30° to promote venous drainage from the head and prevent increased iCP.
NCLEX® Connection: Physiological Adaptation, Illness Management
Active Learning Scenario Key
Using the ATI Active Learning Template: System Disorder
ALTERATION IN HEALTH (DIAGNOSIS): Bacterial meningitis is a bacterial infection that causes an inflammation of the meninges, the membranes that protect the brain and spinal cord.
MEDICATIONS ● Ceftriaxone with vancocin: antibiotics administered to treat the infection.
● Acetaminophen: an antipyretic used to treat a fever. ● Phenytoin: an anticonvulsant given to prevent the client from experiencing a seizure when at risk of iCP.
COMPLICATIONS ● increased iCP, which can lead to seizures, coma, and death. ● syndrome of inappropriate antidiuretic hormone (siAdH), which is due to pressure from inflammation abnormally stimulating the hypothalamus, causing increased secretion of antidiuretic hormone (vasopressin).
● septic emboli can occur as a result of meningitis. This complication can lead to disseminated intravascular coagulation, stroke, or gangrene.
NCLEX® Connection: Physiological Adaptation, Illness Management
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 6 seizUres ANd ePiLePsy 35
UNIT 2 NEUROLOGIC DISORDERSSECTION: CENTRAL NERVOUS SYSTEM DISORDERS
CHAPTER 6 Seizures and Epilepsy
seizures are an abrupt, abnormal, excessive, and uncontrolled electrical discharge of neurons within the brain that can cause alterations in the level of consciousness and/or changes in motor and sensory ability and/or behavior.
epilepsy is the term used to define chronic recurring abnormal brain electrical activity resulting in two or more seizures. seizures resulting from identifiable causes, such as substance withdrawal or fever, are not considered epilepsy.
The international Classification of epileptic seizures uses three broad categories to describe seizures: generalized, partial, and unclassified.
ASSESSMENT
risK FACTOrs ● Genetic predisposition: Absence seizures are more
common in children and tend to occur in families. ● Acute febrile state: Particularly among infants and
children younger than 2 years old. ● Head trauma: Can be early or late onset (up to 9 months), and incidence is increased when the head trauma includes a skull fracture.
● Cerebral edema: Especially when it occurs acutely and seizure activity tends to disappear when the edema is successfully treated.
● Abrupt cessation of antiepileptic drugs (AEDs): As a rebound activity.
● Infection: If intracranial, a result of increased intracranial pressure; if systemic, a result of the persistent febrile state.
● Metabolic disorder: A result of insufficient or excessive chemicals within the brain, such as occurring with hypoglycemia or hyponatremia.
● Exposure to toxins: Especially those associated with pesticides, carbon monoxide, and lead poisoning.
● Stroke: Most likely to occur within the first 24 hr following a stroke as a result of increased intracranial pressure.
● Heart disease: Common cause of new-onset seizures in older adults.
● Brain tumor: If benign, seizures caused by the increased bulk associated with the tumor; if malignant, associated with the ability of the brain tissue to function.
● Hypoxia: Results in a decreased oxygen level of the brain; necessary for neuronal activity.
● Acute substance withdrawal: Dehydration accompanies withdrawal, creating a toxic level of the substance in the body.
● Fluid and electrolyte imbalances: Results in abnormal levels of nutrients required for neuronal function.
● With older adult clients, increased seizure incidence is associated with cerebrovascular diseases.
TRIGGERING FACTORS ● Increased physical activity ● Excessive stress ● Hyperventilation ● Overwhelming fatigue ● Acute alcohol ingestion ● Excessive caffeine intake ● Exposure to flashing lights ● Substances such as cocaine, aerosols, and inhaled
glue products
eXPeCTed FiNdiNGsGeneralized seizuresGeneralized seizure involves both cerebral hemispheres. Generalized seizures can begin with an aura (alteration in vision, smell, hearing, or emotional feeling). Clients can experience five types of generalized seizures.
● Tonic-clonic seizure ◯ A tonic-clonic seizure begins for only a few seconds with a tonic episode (stiffening of muscles) and loss of consciousness.
◯ A 1- to 2-min clonic episode (rhythmic jerking of the extremities) follows the tonic episode.
◯ Breathing can stop during the tonic phase and become irregular during the clonic phase.
◯ Cyanosis can accompany breathing irregularities. ◯ Biting of the cheek or tongue can occur during clonic phase.
◯ Incontinence can also accompany a tonic-clonic seizure.
◯ During the postictal phase, a period of confusion and sleepiness follows the seizure.
● Tonic seizure ◯ Only the tonic phase is experienced. ◯ Clients suddenly lose consciousness and experience sudden increased muscle tone, loss of consciousness, and autonomic manifestations (arrhythmia, apnea, vomiting, incontinence, salivation).
◯ Tonic seizures generally last less than 30 seconds, but some sources indicate they can last several minutes.
● Clonic seizure ◯ Only the clonic phase is experienced. ◯ The seizure lasts several minutes. ◯ During this type of seizure, the muscles contract and relax.
CHAPTER 6
36 CHAPTER 6 seizUres ANd ePiLePsy CONTENT MASTERY SERIES
● Myoclonic seizure ◯ Myoclonic seizures consist of brief jerking or stiffening of the extremities, which can be symmetrical or asymmetrical.
◯ This type of seizure lasts for seconds. ● Atonic or akinetic seizure
◯ Atonic or akinetic seizures are characterized by a few seconds in which muscle tone is lost.
◯ The seizure is followed by a period of confusion. ◯ The loss of muscle tone frequently results in falling.
Partial or focal/local seizurePartial or focal/local seizure involves only one cerebral hemisphere.Clients can experience two types of partial seizures.
● Complex partial seizure ◯ Complex partial seizures have associated automatisms (behaviors that the client is unaware of, such as lip smacking or picking at clothes).
◯ The seizure can cause a loss of consciousness or blackout for several minutes.
◯ Amnesia can occur immediately prior to and after the seizure.
● Simple partial seizure ◯ Consciousness is maintained throughout simple
partial seizures. ◯ Seizure activity can consist of unusual sensations, a sense of déjà vu, autonomic abnormalities such as changes in heart rate and abnormal flushing, unilateral abnormal extremity movements, pain, or offensive smell.
Unclassified or idiopathic seizuresUnclassified or idiopathic seizures do not fit into other categories. These types of seizures account for half of all seizure activity and occur for no known reason.
LABOrATOry TesTs Tests should include alcohol and illicit substance levels, HIV testing, and, if suspected, screen for the presence of excessive toxins.
diAGNOsTiC PrOCedUres ● Electroencephalogram (EEG) records electrical activity
and can identify the origin of seizure activity. ● Magnetic resonance imaging (MRI), computed
tomography (CT) imaging/computed axial tomography (CAT) scan, positron emission tomography (PET) scan, cerebrospinal fluid (CSF) analysis, and skull x-ray can be used to identify or rule out potential causes of seizures.
PATIENT‑CENTERED CARE
NUrsiNG CAreDuring a seizure
● Protect the client’s privacy and the client from injury (move furniture away, hold head in lap if on the floor).
● Position the client to provide a patent airway. ● Be prepared to suction oral secretions. ● Turn the client to the side to decrease the risk
of aspiration. ● Loosen restrictive clothing. ● Do not attempt to restrain the client. ● Do not attempt to open the jaw or insert airway during
seizure activity (can damage teeth, lips, and tongue). ● Do not use padded tongue blades. ● Document onset and duration of seizure and findings
(level of consciousness, apnea, cyanosis, motor activity, incontinence) prior to, during, and following the seizure.
After a seizure ● This is the postictal phase of the seizure episode. ● Maintain the client in a side-lying position to prevent
aspiration and to facilitate drainage of oral secretions. ● Check vital signs. ● Assess for injuries. ● Perform neurological checks. ● Allow the client to rest if necessary. ● Reorient and calm the client, who might be agitated
or confused. ● Determine if client experienced an aura, which can
indicate the origin of seizure in the brain. ● Try to determine possible trigger (such as fatigue).
MediCATiONs ● Administer prescribed antiepileptic drugs (AEDs), such
as phenytoin. ● Initial goal is to control seizure activity using one
medication. If the chosen medication is not effective, either the dose is increased, or another medication is added or substituted.
● Therapeutic levels are determined by blood tests. These are performed on a routine schedule to ensure compliance and effectiveness of the medication.
● Allergic reactions to these medications are rare, yet can occur immediately or late in therapy. If the client is allergic, another medication may be substituted.
CLIENT EDUCATION ● Take medications at the same time every day to enhance
effectiveness. ● The potential to develop tolerance to antiseizure
medications over time is called drug decline. This can lead to an increase in seizures. Some clients develop sensitivity with age. If drug decline or sensitivity occurs, clients will need blood levels drawn frequently and medication dosages adjusted.
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 6 seizUres ANd ePiLePsy 37
● Be aware of adverse effects and interactions with food or other medications. These are specific to the medication.
● Some antiepileptic medications cause oral gum overgrowth. Routine oral hygiene and dental visits can minimize this adverse effect.
● When using phenytoin, specific instructions should include avoidance of oral contraceptives, as this medication decreases their effectiveness. Warfarin should also not be given with this medication, as phenytoin can decrease absorption and increase metabolism of oral anticoagulants.
iNTerPrOFessiONAL CAre ● Initiate a social services referral to aid in obtaining
medications if cost will affect the client’s ability to adhere to the medication routine.
● If employment is affected by seizure activity, refer to social agencies for financial support and vocational evaluation.
● If seizure activity affects a school-age child’s performance in the classroom, this condition should be reported to the disability office, which can develop specialized interventions or facilitate an Individualized Education Program (IEP).
● Discrimination on the basis of epilepsy is illegal in all states.
THerAPeUTiC PrOCedUresVagal nerve stimulation and conventional surgical procedures can be helpful for clients whose seizures are not controlled with medication therapy.
Vagal nerve stimulator ● Vagal nerve stimulation is indicated for treatment of partial seizures.
● The vagal nerve stimulator is a device implanted into the left chest wall and connected to an electrode placed on the left vagus nerve.
● This procedure is performed under general anesthesia. ● The device is then programmed to administer intermittent stimulation of the brain via stimulation of the vagal nerve, at a rate specific to the client’s needs.
CLIENT EDUCATION ● In addition to routine stimulation, the client may initiate vagal nerve stimulation by holding a magnet over the implantable device, at the onset of seizure activity. This either aborts the seizure, or lessens its severity.
● Avoid diagnostic procedures, such as MRI, ultrasound diathermy, and the use of microwave ovens and shortwave radios.
Conventional surgical procedures ● Conventional surgical procedures are available for
clients who experience partial or generalized seizures. ● Prior to surgery, AEDs are discontinued and the specific
area of the seizure activity is identified through the use of EEG monitoring. Surgically implanted electrodes can also be used.
● The affected area of the brain can be excised if it is determined that vital brain function will not be affected.
◯ An intracarotid amobarbital (Wada) test can help determine if language or memory would be affected.
◯ Neuropsychological testing can help determine if visuospatial function, memory, language, or cognitive function would be affected.
● Partial corpus callosotomy can be used for clients who are not candidates for conventional surgical procedures. The procedure resects the corpus callosum, preventing neuronal discharges across hemispheres and reduces the severity and frequency of seizures.
● These procedures have associated morbidities, including infection, loss of cerebral function, and a lack of success in preventing seizures.
NURSING ACTIONS ● Provide client education regarding seizure management.
◯ Importance of monitoring AED levels and maintaining therapeutic medication levels
◯ Possible medication interactions (decreased effectiveness of oral contraceptives)
● Encourage the client to wear a medical identification tag at all times.
● Instruct clients who have a history of seizures to research state driving laws. Some states restrict or limit driving for individuals who have a recent history of seizures.
6.1 Vagal nerve stimulator
38 CHAPTER 6 seizUres ANd ePiLePsy CONTENT MASTERY SERIES
COMPLICATIONS
Status epilepticus
This is repeated seizure activity within a 30-min time frame or a single prolonged seizure lasting more than 5 min. The complications associated with this condition are related to decreased oxygen levels, inability of the brain to return to normal functioning, and continued assault on neuronal tissue. This acute condition requires immediate treatment to prevent permanent loss of brain function and death.The usual causes are substance withdrawal, sudden withdrawal from AEDs, head injury, cerebral edema, infection, and metabolic disturbances.
NURSING ACTIONS ● Maintain an airway, provide oxygen, establish IV access,
perform ECG monitoring, and monitor pulse oximetry and ABG results.
● Administer diazepam or lorazepam IV push followed by IV phenytoin or fosphenytoin.
Active Learning Scenario
A nurse is planning care for a client who is experiencing status epilepticus. What concepts should the nurse include in the plan of care? Use the ATi Active Learning Template: Basic Concept to complete this item.
RELATED CONTENT: define the condition.
UNDERLYING PRINCIPLES: describe four possible causes.
NURSING INTERVENTIONS: describe five actions the nurse should plan to take.
Application Exercises
1. A nurse is assessing a client who has a seizure disorder. The client tells the nurse, "i am about to have a seizure." Which of the following actions should the nurse implement? (select all that apply.)
A. Provide privacy.
B. ease the client to the floor if standing.
C. Move furniture away from the client.
d. Loosen the client’s clothing.
e. Protect the client’s head with padding.
F. restrain the client.
2. A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first?
A. Keep the client in a side‑lying position.
B. document the duration of the seizure.
C. reorient the client to the environment.
d. Provide client hygiene.
3. A nurse is providing discharge instructions to a client who has a prescription for phenytoin. Which of the following information should the nurse include?
A. Consider taking an antacid when on this medication.
B. Watch for receding gums when taking the medication.
C. Take the medication at the same time every day.
d. Provide a urine sample to determine therapeutic levels of the medication.
4. A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? (select all that apply.)
A. Avoid overwhelming fatigue.
B. remove caffeinated products from the diet.
C. Limit looking at flashing lights.
d. Perform aerobic exercise.
e. Limit episodes of hypoventilation.
F. Use of aerosol hairspray is recommended.
5. A nurse is completing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following statements should the nurse include in the teaching?
A. “it is safe to use microwaves that are 1,200 watts or less.” .
B. “you should avoid the use of CT scans with contrast.”.
C. “you should place a magnet over the implantable device when you feel an aura occurring.”
d. “it is recommended that you use ultrasound diathermy for pain management.”
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 6 seizUres ANd ePiLePsy 39
Application Exercises Key
1. A. CORRECT: The nurse should implement privacy to minimize the client’s embarrassment.
B. CORRECT: The nurse should ease the client to the floor to prevent falling and injury.
C. CORRECT: The nurse should move the furniture away from the client to prevent injury.
d. CORRECT: The nurse should loosen the client’s clothing to minimize restriction of movement.
e. CORRECT: The nurse should protect the client’s head from injury by placing the client’s head in her lap or using a pillow or blanket under the head during a seizure.
F. The nurse should not restrain the client. restraint can increase the client’s risk for injury or more seizure activity.
NCLEX® Connection: Physiological Adaptation, Alterations in Body Systems
2. A. CORRECT: The greatest risk to the client is aspiration during the postictal phase. Therefore, the priority intervention is to keep the client in a side‑lying position so secretions can drain from the mouth keeping the airway patent.
B. The nurse should document the duration of the seizure in the client’s medical record, but there is another action that the nurse should take first.
C. The nurse should reorient the client to the environment because the client can feel confused, but there is another action that the nurse should take first.
d. The nurse should provide client hygiene if the client experienced incontinence during the seizure, but there is another action that the nurse should take first.
NCLEX® Connection: Physiological Adaptation, Alterations in Body Systems
3. A. The nurse does not need to instruct the client to consider taking an antacid, because phenytoin does not cause any gastrointestinal adverse effects.
B. The nurse should instruct the client that phenytoin causes overgrowth of the gums.
C. CORRECT: The nurse should instruct the client to take phenytoin at the same time every day to enhance effectiveness.
d. The nurse should instruct the client to have periodic blood tests to determine the therapeutic level of phenytoin.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Medication Administration
4. A. CORRECT: The nurse should instruct the client to avoid overwhelming fatigue, which can trigger a seizure by stimulating abnormal electrical neuron activity.
B. CORRECT: The nurse should instruct the client to remove caffeinated products from the diet, which can trigger a seizure by stimulating abnormal electrical neuron activity.
C. CORRECT: The nurse should instruct the client to refrain from looking at flashing lights, which can trigger a seizure by stimulating abnormal electrical neuron activity.
d. The nurse should instruct the client to avoid vigorous physical activity, which can help to avoid triggering a seizure.
e. The nurse should instruct the client to limit excess hyperventilation, which can trigger a seizure by stimulating abnormal electrical neuron activity.
F. The nurse should instruct the client to avoid using aerosol hairspray, which can trigger a seizure by stimulating abnormal electrical neuron activity.
NCLEX® Connection: Physiological Adaptation, Alterations in Body Systems
5. A. The nurse should instruct the client to avoid using a microwave, regardless of wattage, which can affect the function of the stimulator.
B. The nurse should instruct the client to avoid Mris, which can affect the function of the stimulator.
C. CORRECT: The nurse should instruct the client to hold a magnet over the implantable device when an aura occurs so as to decrease seizure activity.
d. The nurse should instruct the client to avoid the use of ultrasound diathermy for pain management because of its effect on the function of the stimulator.
NCLEX® Connection: Reduction of Risk Potential, Therapeutic Procedures
Active Learning Scenario Key
Using the ATI Active Learning Template: Basic Concept
RELATED CONTENT: status epilepticus is repeated seizure activity within a 30‑min time frame or a single prolonged seizure lasting more than 5 min.
UNDERLYING PRINCIPLES ● substance withdrawal ● Withdrawal from antiepileptic medication ● infection ● Head injury ● Cerebral edema ● Metabolic disturbances
NURSING INTERVENTIONS ● Maintain a patent airway. ● Perform eCG monitoring. ● review ABG results. ● establish iV access. ● Provide oxygen. ● Monitor pulse oximetry. ● Administer lorazepam or diazepam. ● Administer phenytoin or fosphenytoin.
NCLEX® Connection: Physiological Adaptation, Alterations in Body Systems
40 CHAPTER 6 seizUres ANd ePiLePsy CONTENT MASTERY SERIES
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 7 PArKiNsON’s diseAse 41
UNIT 2 NEUROLOGIC DISORDERSSECTION: CENTRAL NERVOUS SYSTEM DISORDERS
CHAPTER 7 Parkinson’s DiseaseParkinson’s disease (Pd) is a progressively debilitating disease that grossly affects motor function. it is characterized by four primary findings: tremor, muscle rigidity, bradykinesia (slow movement), and postural instability. These findings occur due to overstimulation of the basal ganglia by acetylcholine.
The secretion of dopamine and acetylcholine in the body produce inhibitory and excitatory effects on the muscles respectively.
Overstimulation of the basal ganglia by acetylcholine occurs because degeneration of the substantia nigra results in decreased dopamine production. This allows acetylcholine to dominate, making smooth, controlled movements difficult.
Treatment of Pd focuses on increasing the amount of dopamine or decreasing the amount of acetylcholine in a client’s brain.
ASSESSMENT
risK FACTOrs ● Onset of findings between age 40 to 70 ● More common in males ● Genetic predisposition ● Exposure to environmental toxins and chemical solvents ● Chronic use of antipsychotic medication
eXPeCTed FiNdiNGs ● Report of fatigue ● Report of decreased manual dexterity over time
PHYSICAL ASSESSMENT FINDINGS ● Stooped posture ● Slow, shuffling, and propulsive gait ● Slow, monotonous speech ● Tremors/pill-rolling tremor of the fingers ● Muscle rigidity (rhythmic interruption,
mildly restrictive, total resistance to movement) ● Bradykinesia/akinesia ● Masklike expression ● Autonomic findings (orthostatic hypotension,
flushing, diaphoresis) ● Difficulty chewing and swallowing
◯ Drooling ◯ Dysarthria ◯ Progressive difficulty with ADLs ◯ Mood swings ◯ Cognitive impairment (dementia)
LABOrATOry TesTs ● There are no definitive diagnostic procedures. ● Diagnosis is made based on manifestations, their
progression, and by ruling out other diseases. (7.1)
CHAPTER 7 Online Video: Assessment Findings with Parkinson’s Disease
7.1 The five stages of Parkinson’s disease involvement
As Parkinson’s disease is a progressive disease, there are five stages of involvement.
STAGE I: Unilateral shaking or tremor of one limb.
STAGE II: Bilateral limb involvement occurs, making walking and balance difficult. Masklike face; slow, shuffling gait.
STAGE III: Physical movements slow down significantly, affecting walking more. Postural instability.
STAGE IV: Tremors can decrease but akinesia and rigidity make day‑to‑day tasks difficult.
STAGE V: Client unable to stand or walk, is dependent for all care, and might exhibit dementia.
42 CHAPTER 7 PArKiNsON’s diseAse CONTENT MASTERY SERIES
PATIENT‑CENTERED CARE
NUrsiNG CAre ● Administer medications at prescribed times. Monitor
medication effectiveness, and make recommendations for changes in dosage and time of administration to provide best coverage.
● Monitor swallowing, and maintain adequate nutrition and weight. Consult speech and language therapist to assess swallowing if the client demonstrates a risk for choking.
◯ Consult the client’s dietitian for appropriate diet, which often includes semisolid foods and thickened liquids.
◯ Document the client’s weight at least weekly. ◯ Keep a diet intake log. ◯ Encourage fluids and document intake. ◯ Provide smaller, more frequent meals. ◯ Sit the client upright to eat or drink. ◯ Consult with an occupational therapist for adaptive eating devices.
◯ Evaluate the need for high-calorie, high-protein supplements to maintain the client’s weight.
● Maintain client mobility for as long as possible. ◯ Encourage exercise, such as yoga (can also improve mental status).
◯ Encourage use of assistive devices as disease progresses.
◯ Encourage range-of-motion (ROM) exercises. ◯ Teach the client to stop occasionally when walking to slow down speed and reduce risk for injury.
◯ Pace activities by providing rest periods. ◯ Assist with ADLs as needed (hygiene, dressing).
● Promote client communication for as long as possible. ◯ Teach the client facial muscle strengthening exercises. ◯ Encourage the client to speak slowly and to
pause frequently. ◯ Use alternate forms of communication as appropriate. ◯ Refer the client to a speech-language pathologist.
● Monitor mental and cognitive status. ◯ Observe for manifestations of depression and dementia.
◯ Provide a safe environment (no throw rugs, encourage the use of an electric razor).
◯ Assess personal and family coping with the client’s chronic, degenerative disease.
◯ Provide a list of community resources (support groups) to the client and family.
◯ Refer the client to a social worker or case manager as condition advances (financial issues, long-term home care, and respite care).
MediCATiONs ● Can take several weeks of use before improvement of
manifestations is seen. ● While the client is taking a combination of medications,
maintenance of therapeutic medication levels is necessary for adequate control.
Dopaminergics ● When given orally, medications such as levodopa
are converted to dopamine in the brain, increasing dopamine levels in the basal ganglia.
● Dopaminergics may be combined with carbidopa to decrease peripheral metabolism of levodopa, requiring a smaller dose to make the same amount available to the brain. Adverse effects are subsequently less.
● Due to medication tolerance and metabolism, the dosage, form of medication, and administration times must be adjusted to avoid periods of poor mobility.
NURSING ACTIONS: Monitor for the “wearing-off” phenomenon and dyskinesias (problems with movement), which can indicate the need to adjust the dosage or time of administration or the need for a medication holiday.
Dopamine agonists
Dopamine agonists (bromocriptine, ropinirole, pramipexole) activate release of dopamine. May be used in conjunction with a dopaminergic for better results.
NURSING ACTIONS: Monitor for orthostatic hypotension, dyskinesias, and hallucinations.
Anticholinergics
Anticholinergics, such as benztropine and trihexyphenidyl, help control tremors and rigidity.
NURSING ACTIONS: Monitor for anticholinergic effects (dry mouth, constipation, urinary retention, acute confusion).
Catechol O‑methyltransferase (COMT) inhibitors
COMT inhibitors, such as entacapone, decrease the breakdown of levodopa, making more available to the brain as dopamine. Can be used in conjunction with a dopaminergic and dopamine agonist for better results.
NURSING ACTIONS ● Monitor for dyskinesia/hyperkinesia when used
with levodopa. ● Assess for diarrhea. ● Dark urine is a normal finding.
Monoamine oxidase type B (MAO‑B) inhibitors
MAO-B inhibitors, such as selegiline and rasagiline, inhibit monoamine oxidase type B activity and increase dopamine levels. They reduce the wearing-off phenomenon when administered concurrently with levodopa.
NURSING ACTIONS: Severe reactions can occur when these medications are administered with sympathomimetics, meperidine, and fluoxetine.
CLIENT EDUCATION: Avoid foods high in tyramine, which can cause hypertensive crisis.
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 7 PArKiNsON’s diseAse 43
Antivirals
Antivirals, such as amantadine, stimulate release of dopamine and prevent its reuptake.
NURSING ACTIONS ● Monitor for discoloration of the skin that subsides when
amantadine is discontinued. ● Client might experience anxiety, confusion, and
anticholinergic effects.
THerAPeUTiC PrOCedUres
Stereotactic pallidotomy or thalamotomy ● Strict eligibility criteria generally includes those who
have not responded to other therapies. ● Stereotactic pallidotomy and thalamotomy causes the
destruction of a small portion of the brain within the globus pallidus or thalamus through the use of brain imaging and electrical stimulation.
● Target area is identified with a CT scan or an MRI. ● Mild electrical stimulation is provided through a burr
hole to a target area. ● Client is assessed for a decrease in tremors and
muscle rigidity. ● When a decrease is elicited, a temporary lesion is
formed and the client is reassessed. ● If symptomatic relief is demonstrated (such as
alleviation of tremors and rigidity), a permanent lesion is made.
NURSING ACTIONS: Assess for a neurologic impairment and brain hemorrhage postoperatively.
Deep brain stimulation ● An electrode is implanted in the thalamus. ● A current is delivered through a small pulse generator
implanted under the skin of the upper chest. Electrical stimulation from deep rain stimulation impulses decreases tremors and involuntary movements, and can decrease medications required to control PD.
NURSING ACTIONS: Monitor for infection, brain hemorrhage, or stroke-like findings.
iNTerPrOFessiONAL CAre ● Because PD is a degenerative neurologic disorder,
long-term treatment and care must be accommodated. ● During the later stages of the disorder, the client needs
referrals to and support from disciplines such as speech therapists, occupational therapists, physical therapists, and social service/case management.
COMPLICATIONS
Aspiration pneumonia
As PD advances in severity, alterations in chewing and swallowing worsen, increasing the risk for aspiration.
NURSING ACTIONS ● Use swallowing precautions to decrease the risk for
aspiration. ● Develop an individual dietary plan based on the speech
therapist’s recommendations. ● Have a nurse in attendance when the client is eating. ● Encourage the client to eat slowly and chew thoroughly
before swallowing. ● Feed the client in an upright position and have suction
equipment on standby. ● Evaluate need for enteral feedings to maintain weight
and prevent aspiration as PD progresses.
Altered cognition (dementia, memory deficits)
Clients in advanced stages of PD can exhibit altered cognition in the form of dementia and memory loss.
NURSING ACTIONS ● Acknowledge the client’s feelings. ● Provide for a safe environment. ● Develop a comprehensive plan of care with the family,
client, and interprofessional team.
44 CHAPTER 7 PArKiNsON’s diseAse CONTENT MASTERY SERIES
Application Exercises
1. A nurse is caring for a client who displays manifestations of stage iii Parkinson’s disease. Which of the following actions should the nurse include?
A. recommend a community support group.
B. integrate a daily exercise routine.
C. Provide a walker for ambulation.
d. Perform AdLs for the client.
2. A nurse is developing a plan of care for the nutritional needs of a client who has stage iV Parkinson’s disease. Which of the following actions should the nurse include? (select all that apply.)
A. Provide three large balanced meals daily.
B. record diet and fluid intake daily.
C. document weight every other week.
d. Offer cold fluids such as milkshakes.
e. Offer nutritional supplements between meals.
3. A nurse is reinforcing teaching with a client who has Parkinson’s disease and has a new prescription for bromocriptine. Which of the following instructions should the nurse include?
A. rise slowly when standing.
B. expect urine to become dark‑colored.
C. Avoid foods containing tyramine.
d. report any skin discoloration.
4. A nurse is assessing a client for manifestations of Parkinson’s disease. Which of the following are expected findings? (select all that apply.)
A. decreased vision
B. Pill‑rolling tremor of the fingers
C. shuffling gait
d. drooling
e. Bilateral ankle edema
F. Lack of facial expression
5. A nurse is caring for a client who has Parkinson’s disease and is starting to display bradykinesia. Which of the following is an appropriate action by the nurse?
A. Teach the client to walk more quickly when ambulating.
B. Complete passive range‑of‑motion exercises daily.
C. Place the client on a low‑protein, low‑calorie diet.
d. Give the client extra time to perform activities.
Active Learning Scenario
A nurse is preparing a plan of care for a client who has a new diagnosis of Parkinson’s disease. What should the nurse include in the plan of care? Use the ATi Active Learning Template: system disorder to complete this item.
ALTERATION IN HEALTH (DIAGNOSIS): define Parkinson’s disease.
COMPLICATIONS: identify four.
NURSING CARE: describe six nursing actions.
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 7 PArKiNsON’s diseAse 45
Application Exercises Key
1. A. The client/family should be involved in a community support group at the onset of the disease process to enhance coping mechanisms.
B. The client should perform daily exercises with the onset of the disease process to promote mobility and independence for as long as possible.
C. CORRECT: The client should use a walker for ambulation in stage iii of Parkinson’s disease because movement slows down significantly and gait disturbances occur.
d. The client loses the ability to perform AdLs during stage V of Parkinson’s disease and is dependent on others for care at that time. during earlier stages, the client should be encouraged to remain as independent as possible.
NCLEX® Connection: Safety and Infection Control, Accident/Error/Injury Prevention
2. A. Plan to provide small, frequent meals during the day to maintain adequate nutrition.
B. CORRECT: record the client’s diet and fluid intake daily to assess for dietary needs and to maintain adequate nutrition and hydration.
C. document the client’s weight weekly to identify weight loss and intervene to maintain the client’s weight.
d. CORRECT: Provide cold fluids such as milkshakes. Thick and cold fluids are tolerated easier by the client.
e. CORRECT: Offer nutritional supplements between meals to maintain the client’s weight.
NCLEX® Connection: Basic Care and Comfort, Nutrition and Oral Hydration
3. A. CORRECT: Orthostatic hypotension is a common adverse effect of bromocriptine, a dopamine receptor agonist. Therefore, rising slowly when standing up will decrease the risk of dizziness and lightheadedness.
B. The client should expect urine to turn dark when taking entacapone, a COMT inhibitor. dark urine is not an expected finding when taking bromocriptine.
C. The client should avoid tyramine in the diet when taking selegiline, a monoamine type B inhibitor. However, bromocriptine does not interact with foods that contain tyramine.
d. skin discoloration is an adverse effect of amantadine, an anti‑viral medication. However, it is not an adverse effect of bromocriptine.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Adverse Effects/Contraindications/Side Effects/Interactions
4. A. decreased vision is not an expected finding in a client who has Pd.
B. CORRECT: The client who has Pd can manifest pill‑rolling tremors of the fingers due to overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult.
C. CORRECT: The client who has Pd can manifest shuffling gait because of overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult.
d. CORRECT: The client who has Pd can manifest drooling because of overstimulation of the basal ganglia by acetylcholine, making the controlled movement of swallowing secretions difficult.
e. Bilateral ankle edema is not an expected finding in a client who has Pd, but can be an adverse effect of certain medications used for treatment.
F. CORRECT: The client who has Pd can manifest a lack of facial expressions due to overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult.
NCLEX® Connection: Physiological Adaptation, Pathophysiology
5. A. The client who has Pd develops a propulsive gait and tends to walk increasingly rapidly. The client should be reminded to stop occasionally when walking to prevent a propulsive gait and decrease the risk for falls.
B. encourage active, not passive, range‑of‑motion exercises to promote mobility in the client who has Pd and is displaying bradykinesia.
C. The client who has Pd often requires high‑calorie, high‑protein supplements between meals in order to maintain adequate weight.
d. CORRECT: Bradykinesia is abnormally slowed movement and is seen in clients who have Pd. The client should be given extra time to perform activities and should be encouraged to remain active.
NCLEX® Connection: Reduction of Risk Potential, System Specific Assessments
Active Learning Scenario Key
Using the ATI Active Learning Template: System Disorder
ALTERATION IN HEALTH (DIAGNOSIS): Parkinson’s disease is a debilitating condition that progresses to complete dependent care. The disease involves a decrease in dopamine production and an increase in secretion of acetylcholine, causing resting tremor, slowed movement, and muscular rigidity.
COMPLICATIONS ● Aspiration due to pharyngeal muscle involvement making swallowing difficult ● Orthostatic hypotension, slow movement, and muscle rigidity ● Change in speech pattern: slow, monotonous speech ● Altered emotional changes that can include depression and fear
NURSING CARE ● Add thickener to liquids to prevent aspiration. ● Consult with a dietitian about appropriate diet. ● encourage periods of rest between activities. ● Allow adequate time to rise slowly from a sitting to standing position. ● encourage slower speech when expressing thoughts. ● Observe for manifestations of depression and dementia.
NCLEX® Connection: Physiological Adaptation, Illness Management
46 CHAPTER 7 PArKiNsON’s diseAse CONTENT MASTERY SERIES
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 8 ALzHeiMer’s diseAse 47
UNIT 2 NEUROLOGIC DISORDERSSECTION: CENTRAL NERVOUS SYSTEM DISORDERS
CHAPTER 8 Alzheimer’s DiseaseAlzheimer’s disease (Ad) is a nonreversible type of dementia that progressively develops over many years. A framework made up of seven stages has been designed to categorize the disease and its manifestations. The framework is based on three general stages: early stage, mid stage, and late stage.
dementia is defined as multiple cognitive deficits that impair memory and can affect language, motor skills, and/or abstract thinking. The percentage of dementia attributable to Ad ranges from 60% to 90%.
The mean duration of survival after diagnosis is approximately 10 years, but some people can live with the disease for up to 20 years.
Ad is most likely to occur in clients in their 60s and 70s. However, it can be diagnosed as early as 40. Age, sex, and genetics, are known risk factors for Ad, which usually occurs after the age of 65.
Ad is characterized by memory loss, problems with judgment, and changes in personality. As the disease progresses, severe physical decline occurs along with deteriorating cognitive functions.
sTAGes OF ALzHeiMer’s diseAseThe progression of Alzheimer’s disease can be different for each client. While there is no universal scale for the stages and manifestations, the following is an example of one scale.
Mild Alzheimer’s (early stage) ● Memory lapses ● Losing or misplacing items ● Difficulty concentrating and organizing ● Unable to remember material just read ● Still able to perform ADLs ● Short-term memory loss noticeable to close relations ● Trouble remembering names when introduced to
new people ● Greater difficulty performing tasks in a worse setting
Moderate Alzheimer’s (middle stage) ● Forgetting events of one’s own history ● Difficulty performing tasks that require planning and
organizing (paying bills, managing money) ● Difficulty with complex mental arithmetic ● Personality and behavioral changes: appearing
withdrawn or subdued, especially in social or mentally challenging situations; compulsive; repetitive actions
● Changes in sleep patterns ● Can wander and get lost ● Can be incontinent ● Clinical findings that are noticeable to others
Severe Alzheimer’s (late stage) ● Losing ability to converse with others ● Assistance required for ADLs ● Incontinence ● Losing awareness of one’s environment ● Progressing difficulty with physical abilities (walking,
sitting, and eventually swallowing) ● Eventually losses all ability to move; can develop stupor
and coma ● Death frequently related to choking or infection ● Vulnerable to infection, especially pneumonia, which
may become lethal
ASSESSMENTMini Mental State Examination (MMSE), set test using FACT, Short Blessed Test, or Clock Drawing Test is used.
risK FACTOrs ● Advanced age ● Chemical imbalances ● Family history of AD or Down syndrome ● Genetic predisposition, apolipoprotein E ● Environmental agents (herpes virus, metal, or
toxic waste) ● Previous head injury ● Sex (female) ● Ethnicity/race (African American and Hispanic people
are at an increased risk for the development of AD than non-Hispanic white people due to the APOE and ABCA7 genes)
eXPeCTed FiNdiNGsThe progression of Alzheimer’s disease can be different for each client. There is no universal scale for the stages and manifestations.FOR MORE INFORMATION, SEE MENTAL HEALTH CHAPTER 17:
NEUROCOGNITIVE DISORDERS
CHAPTER 8
48 CHAPTER 8 ALzHeiMer’s diseAse CONTENT MASTERY SERIES
LABOrATOry TesTs ● No specific lab test can definitively diagnose AD. ● Several lab tests can rule out other causes of dementia. ● A genetic test for the presence of apolipoprotein can
determine if there is an increased risk of AD, but it does not specifically diagnose AD. The presence of the protein increases the likelihood that dementia is due to AD.
diAGNOsTiC PrOCedUres ● There is no definitive diagnostic procedure, except brain
tissue examination upon death. ● Magnetic resonance imaging (MRI), computed
tomography (CT) imaging/computed axial tomography (CAT) scan, positron emission tomography (PET) scan, and electroencephalogram (EEG) may be performed to rule out other possible causes of findings.
● A lumbar puncture may be performed for laboratory testing of cerebral spinal fluid for soluble beta protein precursor (sBPP). Beta amyloid protein normally assists in growth and protection of nerve cells. The presence of low levels of sBPP supports the diagnosis of AD.
PATIENT‑CENTERED CARE
NUrsiNG CAre ● Assess cognitive status, memory, judgment, and
personality changes. ● Initiate bowel and bladder program based on a
set schedule. ● Encourage the client and family to participate in an AD
support group. ● Provide a safe environment.
◯ Frequent monitoring/visual checks. ◯ Keep client from stairs, elevators, exits. ◯ Remove or secure dangerous items in the client’s environment.
● Provide frequent walks to reduce wandering. ● Maintain a sleeping schedule, and monitor for irregular
sleeping patterns. ● Provide verbal and nonverbal ways to communicate with
the client. ● Offer snacks or finger foods if the client is unable to sit
for long periods of time. ● Check skin weekly for breakdown.
8.1 Alzheimer’s disease stages and manifestations
Mild Alzheimer’s (early stage)NO APPARENT MANIFESTATION
● Normal function ● Manifestation: No memory problems.
STAGE 2: Forgetfulness ● (Can be normal age‑related changes or very early manifestations of Ad)
● Manifestations ◯ Forgetfulness, especially of everyday objects (eyeglasses or wallet).
◯ No memory problems evident to provider, friends, or coworkers.
STAGE 3: Mild Cognitive decline ● (Problems with memory or concentration can be measurable in clinical testing or during a detailed medical interview)
● Mild cognitive deficits, including losing or misplacing important objects.
● Manifestations ◯ decreased ability to plan. ◯ short‑term memory loss noticeable to close relatives.
◯ decreased attention span. ◯ difficulty remembering words or names.
◯ difficulty in social or work situations. ◯ Can get lost when driving.
Moderate Alzheimer’s (middle stage)STAGE 4: Mild to moderate Cognitive decline
● Medical interview will detect clear‑cut deficiencies.
● Manifestations ◯ Personality changes: appearing withdrawn or subdued, especially in social or mentally challenging situations.
◯ Obvious memory loss. ◯ Limited knowledge and memory of recent occasions, current events, or personal history.
◯ difficulty performing tasks that require planning and organizing (paying bills or managing money).
◯ difficulty with complex mental arithmetic.
◯ depression and social withdrawal can occur.
STAGE 5: Moderate cognitive decline ● Manifestations
◯ increasing cognitive deficits emerge. ◯ inability to recall important details such as address, telephone number, or schools attended, but memory of information about self and family remains intact.
◯ Assistance with AdLs becomes necessary.
◯ disorientation and confusion as to time and place.
Severe Alzheimer’s (late stage)STAGE 6: Moderate to severe cognitive decline
● Manifestations ◯ Memory difficulties continue to worsen. ◯ Loss of awareness of recent events and surroundings.
◯ Can recall own name, but unable to recall personal history.
◯ significant personality changes are evident (delusions, hallucinations, and compulsive behaviors).
◯ Wandering behavior. ◯ requires assistance with AdLs such as dressing, toileting, and grooming.
◯ Normal sleep/wake cycle is disrupted. ◯ increased episodes of urinary and fecal incontinence.
STAGE 7: severe cognitive decline ● Manifestations
◯ Ability to respond to environment, speak, and control movement is lost.
◯ Unrecognizable speech. ◯ General urinary incontinence. ◯ inability to eat without assistance and impaired swallowing.
◯ Gradual loss of all ability to move extremities (ataxia).
Refer to Review Module: Mental Health: Chapter 17: Neurocognitive Disorders on Alzheimer’s Disease.
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 8 ALzHeiMer’s diseAse 49
● Provide cognitive stimulation. ◯ Offer varied environmental stimulations (walks, music, craft activities).
◯ Keep a structured environment and introduce change gradually (client’s daily routine or a room change).
◯ Use a calendar to assist with orientation. ◯ Use short directions when explaining an activity or care the client needs, such as a bath.
◯ Be consistent and repetitive. ◯ Use therapeutic touch.
● Provide memory training. ◯ Reminisce with the client about the past. ◯ Use memory techniques, such as making lists and rehearsing.
◯ Stimulate memory by repeating the client’s last statement.
● Avoid overstimulation. (Keep noise and clutter to a minimum, and avoid crowds.)
● Promote consistency by placing commonly used objects in the same location and using a routine schedule.
◯ Reality orientation (early stages) ◯ Easily viewed clock and single-day calendar ◯ Pictures of family and pets ◯ Frequent reorientation to time, place, and person
● Validation therapy (later stages) ◯ Acknowledge the client’s feelings. ◯ Don’t argue with the client; this will lead to the client
becoming upset. ◯ Reinforce and use repetitive actions or ideas cautiously.
● Promote self-care as long as possible. Assist with activities of daily living as appropriate.
● Speak directly to the client in short, concise sentences. ● Reduce agitation. (Use calm, redirecting statements.
Provide a diversion.) ● Provide a routine toileting schedule.
MediCATiONs ● Most medications for clients who have dementia
attempt to target behavioral and emotional problems (anxiety, agitation, combativeness, depression).
● These medications include antipsychotics, antidepressants, and anxiolytics. Closely monitor clients receiving these medications for adverse effects.
● AD medications temporarily slow the course of the disease and do not work for all clients.
◯ Pharmacotherapeutics is based on the theory that AD is a result of depleted levels of the enzyme acetyltransferase, which is necessary to produce the neurotransmitter acetylcholine.
◯ Benefits for clients who do respond to medication include improvements in cognition, behavior, and function.
● If a client fails to improve with one medication, a trial of one of the other medications is warranted.
◯ Donepezil prevents the breakdown of acetylcholine (ACh), which increases the amount of ACh available. This results in increased nerve impulses at the nerve sites.
◯ Memantine is the first of a new classification of medications with a low-to-moderate affinity. It blocks nerve cell damage caused by excess glutamate. It has shown to reduce client deterioration. Memantine may be given in conjunction with donepezil.
◯ Cholinesterase inhibitors help slow this process.
NURSING ACTIONS ● Observe for frequent stools or upset stomach. ● Monitor for dizziness or headache. The client can feel
lightheaded or have an unsteady gait. ● Use caution when administering this medication to clients
who have asthma or COPD, as lung problems can worsen.
THerAPeUTiC PrOCedUresALTERNATIVE THERAPY
● Estrogen therapy for females can prevent Alzheimer’s disease, but it is not useful in decreasing the effects of existing dementia.
● Ginkgo biloba, an herbal product taken to increase memory and blood circulation, can cause a variety of adverse effects and medication interactions. If a client is using ginkgo biloba or other nutritional supplements, that information should be shared with providers.
COMPLEMENTARY MEDICINE ● Massage the client before bedtime to reduce stress and
promote sleep. ● Essential oils (lavender, bergamot) can be used to
promote relaxation and assist with sleeping.
iNTerPrOFessiONAL CAre ● Encourage the client and family to seek legal counsel
regarding advanced directives, guardianship, or durable medical power of attorney.
● Refer the client and family to social services and case managers for possible adult day care facilities or long-term care facilities.
● Refer the client and family to the Alzheimer’s Association and community outreach programs. This can include family support groups, in-home care, or respite care.
● Review the resources available to the family as the client’s health declines. Include long-term care options. A variety of home care and community resources, such as respite care, can be available to the family in many areas of the country. Some respite care allows the client to remain at home rather than in a facility.
50 CHAPTER 8 ALzHeiMer’s diseAse CONTENT MASTERY SERIES
CLieNT edUCATiON ● Refer to social services and case managers for long-
term/home management, Alzheimer’s Association, community outreach programs, and support groups.
● Educate family/caregivers about illness, methods of care, medications, and adaptation of the home environment.
● Provide information about care for seizures that can happen late in the disease.
● Provide strategies to reduce caregiver stress.
Home safety measures ● Remove scatter rugs. ● Install door locks that cannot be easily opened, and
place alarms on doors. ● Keep a lock on the water heater and thermostat, and
keep the water temperature at a safe level. ● Provide good lighting, especially on stairs. ● Install handrails on stairs and mark step edges with
colored tape. ● Place the mattress on the floor. ● Remove clutter and clear hallways for walking. ● Secure electrical cords to baseboards. ● Keep cleaning supplies in locked cupboards. ● Install handrails in the bathroom, at bedside, and
in the tub. ● Place a shower chair in the tub. ● Wear a medical identification bracelet if living at home
with a caregiver. ● Enroll in Safe Return Home Program (www.alz.org). ● Participate in an exercise program to maintain mobility.
Application Exercises
1. A nurse is providing teaching to the partner of a client who has Alzheimer’s disease and has a new prescription for donepezil. Which of the following statements by the partner indicates the teaching is effective?
A. “This medication should increase my husband’s appetite.”
B. “This medication should help my husband sleep better.”
C. “This medication should help my husband’s daily function.”
d. “This medication should increase my husband’s energy level.”
2. A nurse working in a long‑term care facility is planning care for a client who has moderate Alzheimer’s (mild or moderate stage). Which of the following interventions should be included in the plan of care?
A. Use a gait belt for ambulation.
B. Thicken all liquids.
C. Provide protective undergarments.
d. reorient the client to self and current events.
3. A nurse is making a home visit to a client who has Ad. The client’s partner states that the client is often disoriented to time and place, is unsteady, and has a history of wandering. Which of the following safety measures should the nurse review with the partner? (select all that apply.)
A. remove floor rugs.
B. Have door locks that can be easily opened.
C. Provide increased lighting in stairwells.
d. install handrails in the bathroom.
e. Place the mattress on the floor.
4. A nurse is caring for a client who has Ad and falls frequently. Which of the following actions should the nurse take first to keep the client safe?
A. Keep the call light near the client.
B. Place the client in a room close to the nurses’ station.
C. encourage the client to ask for assistance.
d. remind the client to walk with someone for support.
5. A nurse is caring for a client who has Alzheimer’s disease. A family member of the client asks the nurse about risk factors for the disease. Which of the following should be included in the nurse’s response? (select all that apply.)
A. exposure to metal waste products
B. Long‑term estrogen therapy
C. sustained use of vitamin e
d. Previous head injury
e. History of herpes infection
Active Learning Scenario
A charge nurse in a long‑term care facility is preparing a program for assistive personnel about caring for a client who has Alzheimer’s disease. What should be included in this program? Use the ATi Active Learning Template: system disorder to complete this item.
NURSING CARE: describe three nursing interventions for each of the following areas.
● Providing cognitive stimulation ● Providing memory training
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 8 ALzHeiMer’s diseAse 51
Application Exercises Key
1. A. donepezil does not affect appetite.B. donepezil does not affect sleep or sleep patterns.C. CORRECT: donepezil helps slow the progression of Ad
and can help improve behavior and daily functions.d. donepezil does not affect energy levels.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Medication Administration
2. A. Ambulation is affected as the client advances into severe Alzheimer’s (late stage).
B. impaired swallowing is a finding as the client advances into severe Alzheimer’s (late stage).
C. The client in severe Alzheimer’s (late stage) experiences episodes of urinary and fecal incontinence.
d. CORRECT: A client who has moderate Alzheimer’s (middle or moderate stage) can require reorientation to self and current events as cognitive function declines.
NCLEX® Connection: Safety and Infection Control, Home Safety
3. A. CORRECT: removing floor rugs can decrease the risk of falling.
B. easy‑to‑open door locks increase the risk for a client who wanders to get out of his home and get lost.
C. CORRECT: Good lighting can decrease the risk for falling in dark areas, such as stairways.
d. CORRECT: installing handrails in the bathroom can be useful for the client to hold on to when his gait is unsteady.
e. CORRECT: By placing the client’s mattress on the floor, the risk of falling or tripping is decreased.
NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions
4. A. Keeping the call light within the client’s reach is an appropriate action, but not the first action because the client might not remember to use it.
B. CORRECT: Using the safety and risk reduction priority‑setting framework, placing the client in close proximity to the nurses’ station for close observation is the first action the nurse should take.
C. encouraging the client to ask for assistance is an appropriate action, but not the first action because the client might not remember to ask for assistance.
d. reminding the client to walk with someone is an appropriate action, but not the first action because the client might not remember to call for assistance.
NCLEX® Connection: Safety and Infection Control, Home Safety
5. A. CORRECT: exposure to metal and toxic waste is a risk factor for Alzheimer’s disease.
B. Long‑term estrogen therapy can prevent Alzheimer’s disease.
C. Long‑term use of vitamin e is not a risk factor for Alzheimer’s disease.
d. CORRECT: A previous head injury is a risk factor for Alzheimer’s disease.
e. CORRECT: A history of herpes infection is a risk factor for Alzheimer’s disease.
NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention
Active Learning Scenario Key
Using the ATI Active Learning Template: System Disorder
NURSING CARE ● Providing cognitive stimulation
◯ Offer varied environmental stimulations (walks, music, craft activities).
◯ Keep a structured environment. introduce change slowly. ◯ Use a calendar to assist with orientation. ◯ Use short directions when explaining care to be provided, such as a bath.
◯ Be consistent and repetitive. ◯ Use therapeutic touch.
● Providing memory training ◯ reminisce about the past. ◯ Help the client make lists and rehearse. ◯ repeat the client’s last statement to stimulate memory.
NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions
52 CHAPTER 8 ALzHeiMer’s diseAse CONTENT MASTERY SERIES
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 9 BrAiN TUMOrs 53
UNIT 2 NEUROLOGIC DISORDERSSECTION: CENTRAL NERVOUS SYSTEM DISORDERS
CHAPTER 9 Brain TumorsBrain tumors occur in any part of the brain, occupy space within the skull, and are classified according to the cell or tissue of origin. Cerebral tumors are the most common.
Types of brain tumors include benign and malignant. examples include malignant gliomas (neuroglial cells), benign meningiomas (meninges), pituitary adenomas, and acoustic neuromas (acoustic cranial nerve).
A secondary classification, supratentorial tumors, occur in the cerebral hemispheres above the tentorium cerebelli. Those below the tentorium cerebelli, such as tumors of the brainstem and cerebellum, are classified as infratentorial tumors.
Brain tumors apply pressure to surrounding brain tissue, resulting in decreased outflow of cerebrospinal fluid, increased intracranial pressure, cerebral edema, and neurologic deficits. Tumors that involve the pituitary gland can cause endocrine dysfunction.
Malignant brain tumors are associated with a high overall mortality rate. Primary malignant brain tumors originate from neuroglial tissue and rarely metastasize outside of the brain. secondary malignant brain tumors are lesions that are metastases from a primary cancer located elsewhere in the body. Cranial metastatic lesions are most common from breast, kidney, lung, skin (melanomas), and gastrointestinal tract cancers.
Benign brain tumors develop from the meninges or cranial nerves and do not metastasize. These tumors have distinct boundaries and cause damage either by the pressure they exert within the cranial cavity and/or by impairing the function of the cranial nerve.
HEALTH PROMOTION/DISEASE PREVENTION
There are no routine screening procedures to detect brain tumors.
ASSESSMENT
risK FACTOrsThe cause is unknown, but several risk factors have been identified.
● Genetics ● Environmental agents ● Exposure to ionizing radiation ● Exposure to electromagnetic fields ● Previous head injury
eXPeCTed FiNdiNGs PHYSICAL ASSESSMENT FINDINGS
● Dysarthria ● Dysphagia ● Positive Romberg sign ● Positive Babinski sign ● Vertigo ● Hemiparesis ● Cranial nerve dysfunction (inability to discriminate
sounds, loss of gag reflex, loss of blink response) ● Papilledema
MANIFESTATIONS SPECIFIC TO SUPRATENTORIAL BRAIN TUMORS
● Severe headache (worse upon awakening but improving over time; worsened by coughing or straining)
● Visual changes (blurring, visual field deficit) ● Focal or generalized seizures ● Loss of voluntary movement or the inability to
control movement ● Change in cognitive function (memory loss,
language impairment) ● Change in personality, inability to control emotions ● Nausea with or without vomiting ● Paralysis
MANIFESTATIONS SPECIFIC TO INFRATENTORIAL BRAIN TUMORS
● Hearing loss or ringing in the ear ● Visual changes ● Facial drooping ● Difficulty swallowing ● Nystagmus, crossed eyes, or decreased vision ● Autonomic nervous system (ANS) dysfunction ● Ataxia or clumsy movements ● Hemiparesis ● Cranial nerve dysfunction (inability to discriminate
sounds, loss of gag reflex, loss of blink response)
LABOrATOry TesTs ● CBC and differential to rule out anemia or malnutrition ● Blood alcohol and toxicology screen to rule out these as
possible causes of altered physical assessment findings ● TB and HIV screening if social conditions warrant
CHAPTER 9 Online Media: Nystagmus, Testing for Romberg Sign, Babinski Reflex
54 CHAPTER 9 BrAiN TUMOrs CONTENT MASTERY SERIES
diAGNOsTiC PrOCedUres ● X-ray, computed tomography (CT) imaging scan,
magnetic resonance imaging (MRI), brain scan, position emission tomography (PET) scan, and cerebral angiography are used to determine the size, location, and extent of the tumor.
● Lumbar puncture (LP) and electroencephalography (EEG) can provide additional information about the tumor.
● LP should not be done if the client has or shows manifestations of increasing intracranial pressure (ICP) to prevent brain herniation.
● Lab tests can be done to evaluate endocrine function, renal status, and electrolyte balance.
● Cerebral biopsy identifies cellular pathology. ◯ This procedure can be performed in the surgical suite or in a radiology specialty suite.
◯ Diagnostic procedure can be used to guide the biopsy, such as a CT or MRI scan. Image guiding systems, which use CT or MRI scan information, can be used in the surgical suite.
◯ A piece of cerebral tissue that appears abnormal on the CT/MRI scan is obtained. This tissue is then sent to pathology, where diagnostic tests are performed.
◯ Benefit: Biopsy is minimally disruptive to the rest of the brain, provides a decreased recovery time, and is not associated with the risks of an open craniotomy.
◯ Negative: Biopsy does not remove or debulk the tumor, the diagnostic determination by pathology can be inconclusive (related to insufficient tissue), and a misdiagnosis can occur if the tumor contains many types of tissue or the specimen is taken from one site.
CLIENT EDUCATION: Adhere to the specific instructions regarding medications.
● If on antiepileptic medications, these must be continued to prevent seizure activity.
● If on aspirin products, these should be discontinued at least 72 hr prior to the procedure to minimize the risk of intracerebral bleeding.
● Other medications can be withheld prior to the procedure.
● Normally, preprocedure activities can be resumed after recovering from the general anesthetic. Care of the incision should include keeping the area clean and dry. If sutures are in place, they need to be removed 1 to 7 days later. Driving or other dangerous activities should be avoided until follow-up appointment occurs and diagnosis is known.
PATIENT‑CENTERED CARE
NUrsiNG CAre ● Maintain airway (monitor oxygen levels, administer
oxygen as needed, monitor lung sounds). ● Monitor neurologic status—in particular, assessing for
changes in level of consciousness, neurologic deficits, and occurrence of seizures.
● Maintain client safety. (Assist with transfers and ambulation, provide assistive devices as needed.)
● Implement seizure precautions. ● Administer medications.
MediCATiONs ● Non-opioid analgesics are used to treat headaches.
◯ Opioid medications are avoided because they tend to decrease level of consciousness.
● Corticosteroids are used to reduce cerebral edema (relieving headaches, improving altered levels of consciousness).
◯ Corticosteroid medications quickly reduce cerebral edema and can be rapidly administered to maximize their effectiveness.
◯ Chronic administration is used to control cerebral edema associated with the presence or treatment of benign or malignant brain tumors.
● Osmotic diuretics decrease fluid content of the brain, resulting in a decrease in intracranial pressure.
● Anticonvulsant medications are used to control or prevent seizure activity.
◯ Anticonvulsant medications suppress the neuronal activity within the brain, which prevents seizure activity.
◯ There are several classifications of antiepileptic medications, each specifically designed to treat specific seizure behavior.
● H2-antagonists are used to decrease the acid content of the stomach, reducing the risk of stress ulcers.
◯ H2-antagonists are administered during acute or stressful periods, such as after surgery, at the initiation of chemotherapy, or during the first several radiation therapy treatments.
◯ The effect of these treatments, together with the necessity of corticosteroids, places the client at risk for stress ulcers. This is primarily preventative treatment.
● Antiemetics are used if nausea (with or without vomiting) is present.
◯ Nausea and vomiting can be present as a result of the increased ICP, the site of the tumor, or the treatment required.
◯ These medications are administered as prescribed, and can be provided as a preventative intervention, especially when the treatment is associated with nausea and vomiting.
● Chemotherapy can be given in conjunction with radiation. However, the blood-brain barrier can prevent adequate doses from reaching the tumor.
RN ADULT MEDICAL SURGICAL NURSING CHAPTER 9 BrAiN TUMOrs 55
iNTerPrOFessiONAL CAre ● Initiate appropriate referrals (social services; support
groups; medical equipment; and physical, speech, and occupational therapy).
● Treatments include steroids, surgery, chemotherapy, conventional radiation therapy, stereotactic radiosurgery, and clinical trials. Chemotherapy and conventional radiation therapy can be administered prior to surgery to reduce the bulk of the tumor, or after surgery to prevent tumor recurrence.
● In most cases when the tumor is benign, surgery is a curative treatment. However, these tumors can regrow. Radiation and chemotherapy can be provided to prevent recurrence.
● Some tumors can be malignant by location, meaning that while the pathology is benign, the location makes the mortality rate associated with them high.
● In cases where the tumor is a metastatic lesion from a primary lesion elsewhere in the body, treatments are palliative. These treatments can consist of surgery, radiation, and chemotherapy, in any combination, and are aimed at controlling intracerebral lesions.
THerAPeUTiC PrOCedUresCraniotomy: complete or partial resection of brain tumor through surgical opening in the skull
PREOPERATIVE NURSING ACTIONS ● Explain the procedure to the client, answering all
appropriate questions and providing emotional support. ● Questions regarding the surgery and its outcomes
should be written, in an effort to ensure all questions are answered.
● The client’s partner should be present to hear the responses and avoid miscommunication.
● If the client takes aspirin, this medication needs to be stopped at least 72 hr prior to the procedure.
● No alcohol, tobacco, anticoagulants, or NSAIDs for 5 days prior to surgery.
● If the client uses alternative/complementary medications or treatments, make these known to the provider.
● A living will and durable power for health care decisions should be completed.
● Administer medications as prescribed. An anti-anxiety or muscle relaxant medication can be administered, if requested, and provided by the provider.
POSTOPERATIVE NURSING ACTIONS ● Closely monitor vital signs and neurologic status,
including using the Glasgow Scale. ● Treat pain adequately. ● Elevate the head of the client 30° for clients who had
supratentorial surgery and in a neutral position to prevent increased ICP. Turn the client to the side or supine to decrease risk of pressure injuries and pneumonia.
● Infratentorial craniotomy clients lie flat and side-lying. Turn side to side every 2 hr for 24 to 48 hr.
● Straining activities (moving up in bed and attempting to have a bowel movement) should be avoided to prevent increased ICP. Postoperative bleeding and seizure activity are the greatest risks.
● Periorbital edema and ecchymosis is not unusual. Treat with cold compresses.
● Assess head dressing every 1 to 2 hr for drainage.
COMPLICATIONS
Syndrome of inappropriate antidiuretic hormone
Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition where fluid is retained as a result of an overproduction of vasopressin or antidiuretic hormone (ADH) from the posterior pituitary gland.
● SIADH occurs when the hypothalamus has been damaged and can no longer regulate the release of ADH.
● Treatment consists of fluid restriction, administration of oral conivaptan, and treatment of hyponatremia, with 3% hypertonic saline solution for severe cases.
● If SIADH is present, the client can have disorientation, headache, vomiting, muscle weakness, decreased LOC, irritability, loss of thirst, and weight gain.
● If severe or untreated, this condition can cause seizures and a coma.
Diabetes insipidus
Diabetes insipidus (DI) is seen most often after supratentorial surgery, especially when involving the pituitary gland or hypothalamus.
● This is a condition where large amounts of urine are excreted as a result of a deficiency of ADH from the posterior pituitary gland.
● The condition occurs when the hypothalamus has been damaged and can no longer regulate the release of ADH.
● Treatment of DI consists of massive fluid replacement, administration of synthetic vasopressin, careful attention to laboratory values, and replacement of essential nutrients as indicated.
56 CHAPTER 9 BrAiN TUMOrs CONTENT MASTERY SERIES
Active Learning Scenario
A nurse is completing preoperative teaching for a client who has a brain tumor and will undergo a craniotomy. What should be included in the teaching? Use the ATi Active Learning Template: Therapeutic Procedure to complete this item.
DESCRIPTION OF PROCEDURE
NURSING INTERVENTIONS: describe three preoperative and three postoperative interventions.
Application Exercises
1. A nurse is caring for a client who is having surgery for the removal of an encapsulated acoustic tumor. Which of the following potential complications should the nurse monitor for postoperatively? (select all that apply.)
A. increased intracranial pressureB. Hemorrhagic shockC. Hydrocephalusd. Hypoglycemiae. seizures
2. A nurse is caring for a client who has just undergone a craniotomy for a supratentorial tumor and has a respiratory rate of 12. Which of the following postoperative prescriptions should the nurse clarify with the provider?
A. dexamethasone 30 mg iV bolus BidB. Morphine
