Adv Med Surg Studyguide 1. Hypoproliferative Anemia a. Iron deficiency anemia i. Clinical manifestations 1. Smooth, sore tongue 2.

Brittle, rigid nails 3. Angular cheliosis (cracks at corners of mouth) ii. Medical mgt 1. Determine cause 2. Supplemental iron b. Folic acid deficiency c. Megoblastic anemia i. B-12 related d. Iron deficiency anemia i. Nursing mgt 1. Teaching is r/t supplemental iron a. Take on empty stomach w/ OJ i. Food (esp dairy) interferes w/ absorption b. Reverse-taper i. Allows body to adjust c. Increase intake of vitamin C i. Contributes to absorption d. High fiber intake, stool softeners i. Whole grains, veges 1. Prevents constipation ii. Supplement causes darkening of the stool iii. Liquid prep can stain teeth e. Anemias in renal disease i. Erythropoietin 1. Decreased production of RBCs 2. Treatment: supplement w/

a. Epogen b. Procrit ii. Folic acid 1. Removed from circulation during dialysis 2. Treatment: supplements a. Folic acid and B-12 are important for the synthesis of DNA f. Megaloblastic anemias i. Deficiencies 1. Folic acid 2. Vit B12 ii. Clinical manifestations 1. Smooth, sore, red tongue 2. Mild diarrhea 3. Neurologic SX a. B12 TX will help w/ the myelin sheath

Anemia Type Iron deficiency anemia (low Fe, ferritin, reticulocytes)

Causes

Manifestations

Populations at risk Preggers, infants, teens, Chronic conditions

Iron intake Pica, cheliosis, Iron loss smooth & red Iron requirements tongue, brittle, spoon-shaped nails, fatigue

Vitamin B12 deficiency (low B12,MCV)

Lack B12 Absorption failure, chronic gastritis, loss of pancreatic secretions Lack folic acid,

Jaundice, neuro, smooth sore beefy red tongue, diarrhea

Vegetarians Chrons Dx Gastroectomy Pernicious Anemia

Folic Acid Deficiency Anemia (low folate, MCV)

Pallor, progressive Alcoholics, Celiac Dx, weakness& fatigue, Pregnancy, TPN shortness of therapy, older adults breath,

2. Hemolytic Anemia a. Sickle Cell i. Inherited disorder 1. Need to carriers to develop sickle cell ii. Crystal-like abnormal hemoglobin shape 1. Change precipitated by hypoxia iii. Clinical manifestations 1. Anemia a. Sickle cell lifespan 10-12 days

b. Jaundice i. d/t cells getting stuck in the biliary c. thrombosis i. occlusions caused by sickled cells 1. occlusion of RBCs happen at joints where sickle RBCs aggregate ii. vaso-occlusive iii. Risk for amputation d/t poor perfusion 1. Need to hydrate them so they can adequately perfuse iv. Sickle cell crisis 1. Sickle (vaso-occlusive) a. Severe pain i. Necrosis b. Organ dysfunctioin i. Spleen, lungs, CNS c. Aplastic i. Rapid decrease in Hgb level 1. Associated human parvovirus infection d. Sequestration i. Collection of sickled cells in organs 1. Autospenectomy e. Medical mgt i. PBSCT ii. Hydroxyurea 1. Chemo agent iii. RBC transfusion iv. Supplements v. IV hydration vi. O2 therapy 2. Nursing interventions a. Managing pain i. Morphine, NSAIDs ii. Positioning 1. Support and elevate affected joints

b. Preventing and managing infection i. Give IV antibiotics and monitor a. Risk increased d/t impaired circulation b. Tissue destructioin c. Interference w/ immune response ii. Monitor iii. Antibiotic administration c. Crisis happens more w/ kids d/t activity level they want to get out and play and that can send them into sickle cell crisis 3. Transfusions a. Blood transfusion administration steps i. 19 guage cath at the minimum ii. Signed consent iii. Assess for previous iv. Use Y tubing v. Follow facility protocol regarding ID vi. Pre-transfusion responsibilities: 1. Usually takes 2 nurses to verify blood once brought to the unit 2. Verify prescription, test donor and recipient blood for compatibility 3. Examine 4. Check expiration date 5. Inspect blood for discoloration, gas bubbles, cloudiness 6. **Have a limited time to infuse blood: w/in 4 hours! b. Adverse transfusion reaction i. STOP transfusion immediately ii. Infuse normal saline iii. Notify healthcare provider iv. Collect blood and urine specimens and send to blood bank along w/ remaining blood product. v. Get a new line! Do not throw away old tubing send back to blood bank c. Transfusion reactions i. Febrile reaction 1. Recipient antibodies react to donor WBCs 2. Manifestations

a. Hypersensitivity reactions i. Recipient antibodies react to donor ii. Uritacaria, flushing, itching iii. SX can occur during or after transfusion iv. Treat w/ Benedryl v. Most of the time its d/t PT getting the wrong blood i. Flushing, burning in veins, HA, itching, chills, eventually will develop lumbar pain and chest pain, tachycardic, dyspnea, b. Febrile (most common) i. Usually noted less than 15 min after transfusion initiated ii. Leukocyte-poor blood can be given to prevent reaction to future blood transfusions (doesnt have a lot of WBCs in bag) 1. For people who have had a reaction to blood in the past. Need to have leukocyte-poor blood c. Hemolytic reaction i. ABO incompatibility ii. Patho: breakdown and agglutination of RBCs causing capillary blockage iii. Release of free hemoglobin into circulation iv. Renal tubule blockage d. Other blood transfusion complications i. Circulatory overload ii. Electrolyte imbalances iii. Transmission of infectious diseases 4. Guidelines for assissting with percutaneous liver biopsy a. Pre-procedure guidelines i. Check coagulation related labs 1. PT, PTT: if its way out of whack, they wont do the biopsy. Platelet count 2. Verify consent 3. Explain procedure 4. Obtain baseline VS b. Post-procedure guidelines i. First 2-3 hours 1. Positioning

a. Right side w/ pillow under costal margin i. To add more pressure b. Client should avoid straining c. Monitor VS i. Q 10-15 min the 1st hour ii. Q 30 min iii. Monitor for bleeding d. Discharge instructions i. Avoid heavy lifting for 1 week ii. Should be on bedrest for the most part iii. Need to get the clotting factors in check 5. Ascites a. Accumulation of fluid in peritoneal space i. Contributing factors 1. Portal HTN a. Vasodilation b. Blue lines on belly is d/t engorgement i. Need to measure their abdominal girth often to assess if ascites is getting worse 2. Increased aldosterone levels a. Increased Na and H2O retention by the kidneys 3. Increased lymphatic flow 4. Decreased albumin levels a. Third spacing i. May hang albumin 5. Self-perpetuating 6. Clinical manifestations a. Increased abdominal girth b. Weight gain c. SOB d. Discomfort e. Varicose veins along abdominal wall (dilated veins) i. Caput medusa 7. Medical mgt

Sodium restriction Diuretics Bedrest Paracentesis i. The nurse gathers the tubing, labels ii. We label it and its sent to the lab to culture it iii. Remove no more than 2 L at a time to r/d risk of BP issues and also to keep electrolytes in check. iv. TIPS 1. Transjugular intrahepatic portosystemic shunt 2. The most important thing to remember before having an abdominal paracentesis is to EMPTY THEIR BLADDER. If they say they cant urinate, scan them and straight-cath them. 6. Esophageal Varices (1128-1129) a. Dilated veins that are prone to rupture i. Bleeding associated w/ mortality 1. Only 50-70% survive 1st episode 2. Mortality rate decreases w/ subsequent episodes b. Clinical manifestations i. Hematemesis ii. Melena iii. Shock c. Assessment and DX findings (1129) i. Endoscopy 1. Prophylactic to see where the bleed is happening a. Treatment of varices before they rupture b. Every 2 years for at-risk clients 2. Diagnostic a. Identify source of bleeding i. May be gastric ulcers (30%) 3. Post-procedure care a. NPO until gag reflex returns b. NPO if further procedures are indicated

a. b. c. d.

d. Medical mgt i. Pharm therapy (1132) 1. Treatment of active bleeding a. Selective vasoconstrictors i. Vasopressin (drip) 1. Contraindicated in PTs w/ CAD 2. Do not give to HTN PTs ii. Somatostatin iii. Sandostatin (octreotide) drip b. Prevention of 1st bleeding episode i. Beta blockers to prevent a first bleeding 1. Inderal (propranolol) 2. Corgard (nadolol) c. Medical mgt i. Balloon tamponade (looks like a tampon put in their throat) 1. Its a band-aid a. Rebleeding rate is 60-70% ii. Endoscopic therapies (1131) 1. Injection sclerotherapy a. Causes thrombus formation and sclerosis 2. Variceal banding (kinda like a lap band) a. Similar to clipping an aneurysm 7. Hepatic encephalopathy and coma (1133) a. CNS depression i. d/t increased serum ammonia levels b. Clinical manifestations i. Mental status/LOC changes ii. Asterixis 1. Flapping tremor of the hands iii. Constructional apraxia 1. Inability to reproduce simple drawings iv. Coma (last stage) 1. One of the most common causes of death associated with liver disease.

c. Medical mgt i. Decrease serum ammonia levels 1. Cephulac (lactulose) a. Changes gut pH i. Prevents absorption of ammonia from gut to blood 2. IV Glucose a. Decreases protein level by prevention of muscle wasting 3. Antibiotic (ATB) a. Decreases number of ammonia-producing gut bacteria 4. Restrict protein intake a. Looking at risk v. benefit ii. Daily monitoring or ammonia level 8. Hepatitis B virus (1141-1144) a. Bloodborne transmission (viruses) i. Spread thru blood-borne pathways 1. Unprotected sex 2. Blood transfusion 3. Hemodialysis 4. From mom to baby during birth ii. Prevention 1. 3 series shot a. Healthcare workers should get iii. Wont get hep D unless you have hep B b. Incubation period 1-6 months c. S/SX i. Insidious and variable 1. May occur w/ or w/out SX 2. May develop arthralgias, rash. d. Med mgt i. Minimize infectivity, liver inflammation and decrease SX. ii. Pharm 1. Antiviral agents a. Lamivudine (Epivir)

b. Adefovir (Hepsera) c. Oral nucleoside analogs for chronic Hep B in the US d. Proteins are restricted. 9. Hepatic cirrhosis (1146-1149) a. End-stage hepatic disease b. Normal tissue replaced by fibrous tissue resulting in dysfunction c. Causes i. Prolonged alcohol abuse is the #1 cause ii. Viral hepatitis (hep b or hep c) iii. Chronic biliary obstruction 1. Very uncommon d. Complications i. bleeding 1. transfusion a. PRBC b. Plasma (FFP) c. Coagulation factors ii. Hepatic encephalopathy iii. Fluid volume excess 1. Peritoneal cavity at full capacity 2. Heart failure d/t increased resistance a. Pulmonary edema 3. Treatment a. Decrease circulating volume i. Diuretics ii. Fluid restriction b. Position client to maximize gas exchange i. Usually high fowlers doesnt work w/ these PTs d/t breathing issues 10. Plan of nursing care: The patient with impaired liver function (1153-1154) a. Nursing interventions i. Encourage PT to verbalize reactions and feelings about changes ii. Assess PTs and fams previous coping strats. iii. Assist and encourage PT to keep up appearance

iv. Assist PT in identifying short-term goals v. Encourage and assist PT in making decisions about care vi. Identify w/ PT resources to provide addl support vii. Assist PT in identifying previous practices that may have bee n harmful to self 11. Cancer of the Liver (1158) a. Primary liver tumor i. Arise from hepatic tissue 1. Usually d/t cirrhosis 2. Rare in the US b. Liver metastasis i. Most common primary sites 1. GI 2. Breast 3. Lungs ii. Typically occurs via portal circulation c. Clinical manifestations i. Continuous dull ache in the right upper quadrant, epigastrium, or back. ii. Anorexia/weight loss iii. Anemia/weakness iv. Other manifestations depend on location 1. Jaundice 2. Ascites d. Medical management (1159) i. Essentially palliative 1. Radiation therapy 2. Chemotherapy 3. Percutaneous biliary drain placement 4. Other nonsurgical TX ii. Surgical mgt 1. Mainly for primary tumors when confined to 1 lobe 2. Not often used for metastasis 3. Cirrhosis decreases success rate of surgical intervention a. Interferes w/ regeneration of liver tissue after surgery

12. Cholielithiasis a. Clinical manifestations i. May be silent, w/ no pain or mild GI SX. 1. SX may be acute or chronic a. Epigastric distress i. Feeling of fullness b. abdominal distention c. vague pain in RUQ i. SX may follow a meal rich in fried or fatty foods ii. Elevated serum bilirubin level 1. Jaundice 2. Pruritis 3. Dark urine and gray stool a. d/t no bilirubin going into stoll b. bilirubin is excreted by kidney rather than bowel iii. Complications 1. Gangrene 2. Perforation a. Leads to peritonitis i. Board like abdomen 3. Empyema a. Little sacks of pus b. Sternal pain c. Labored breathing; increased resps. b. Medical mgt i. The major objectives of medical thereapy are to reduce the incidence of acute episodes of gallbladder pain and cholecystitis by supportive and dietary mgt and, if possible, to remove the cause of cholecystitis by pharmacologic therapy, endoscopic procedures, or surgical interventions. ii. Pharmacologic 1. Actigall (ursodeoxycholic acid) a. Dissolves small stones composed of cholesterol i. Usually takes 6-12 months b. Inhibits synthesis and secretion of cholesterol

c. Dosage is weight based strict weight checks i. Low fat diet, decrease cholesterol iii. Medical mgt 1. Nutritional and supportive therapy a. Avoid dietary fat 2. Non surgical intervention a. Edoscopic procedures i. ERCP ii. Most important assessment after procedure is the gag reflex 1. Must be NPO for the procedure 2. If gag reflex is not back, DO NOT FEED THEM! 13. ERCP a. Complications i. Bleeding especially w/ esophageal varaicies ii. Peritonitis 1. Tender, rigid abdomen 2. Fever 3. Other GI SX iii. Often leads to septicemia and septic shock 14. Laparoscopic cholecystectomy a. 80-90% are removed this way b. Less invasive reduces risk of infection c. Compared to open procedure i. Decreased incidence of complications (less surgical risk) ii. Less pain iii. Quicker recovery (1 week until no restrictions) d. Abdominal cavity is insufflated w/ CO2 to improve visualization of structures i. PT c/o pain in right shoulder e. May convert to open procedure if necessary 15. The patient undergoing surgery for gallbladder disease a. Usually same day surgery b. Week prior to surgery, preadmission occurs i. PT told to avoid smoking to enhance pulmonary recovery postop, and avoid resp issues.

ii. Avoid aspirin and other agents (OTC and herbals) that can alter coagulation and other bio-chemical processes. c. Post-op i. Avoid turning w/out assistance 1. Splint affected side and take shallow breaths to prevent pain during position changes a. Use a pillow or binder over the incision to help reduce pain during position changes. Encourage deep breaths and coughing q hour to expand lungs fully and prevent atelectasis. Begin light exercise (walking) immed. Avoid lifting >5 lbs for 1 week Resume normal diet 1. If PT had fat intolerance prior to surgery, gradually add fat back into diet. vi. Analgesics PRN vii. F/U w/ doc 7-10 days after discharge 16. Acute Pancreatitis a. Cause i. Gallstones ii. Alcohol abuse iii. Infection (less common) b. Patho i. D/t activation of pancreatic enzymes while still inside the organ 1. Pancreatic a. Necrosis b. Hemorrhage increases risk of infection c. Pain radiating to back i. PTs sit similar to COPD PT ii. Pain brought on by food 1. PT is placed NPO when admitted 2. Avoid alcohol 3. Avoid fatty foods c. Forms i. Mild 1. Characterized by edema and inflammation confined to the pancreas. ii. iii. iv. v.

2. Normal function returns w/in 6 months ii. Severe 1. Systemic complications w/ organ failure a. Such as pulmonary insufficiency w/ hypoxia, shock, renal failure, and GI bleeding 2. May result in death (2-10% of cases) d. Complications i. Hemorrhage 1. Transfusion, fluids a. May give platelets to stop hemorrhage 2. Monitor VS, Hgb ii. Imbal. nutrition less than body requirements (r/t to increased metabolism demand associated w/ acute illness and fever) 1. TPN a. Monitor serum glucose 2. Daily weight iii. Impaired gas exchange 1. Semi-fowlers 2. Incentive spirometry 3. Cough and deep breathe 4. Monitoring a. RR and O2sat iv. Hypovolemia v. Hemorrhage vi. Acute renal failure vii. Acute resp failure viii. Pancreatic necrosis ix. Paralytic abcess and pseudocysts x. Diabetes mellitus xi. Hypovolemic or septic shock 17. Chronic pancreatitis a. Inflammatory disorder characterized by progressive destruction of the pancreas. As cells are replaced by fibrous tissue with repeated attacks of pancreatitis, pressure with the pancreas increases. Results in obstruction of the pancreatic and common bile ducts, and the duodenum.

b. Manifestations i. Recurrent attacks of severe upper abdominal and back pain accompanied by vomiting ii. Weight loss c. Medical mgt i. Analgesics 1. Nonopioid, antioxidants ii. Glucose mgt 1. Insulin 2. Oral antidiabetic agts iii. Pancreatic enzyme replacement DO NOT CRUSH!!! iv. Surgery may be an option 1. May need to do a cholesectomy v. Octeotide to stop bleeding especially w/ variaces vi. May give H2 blockers, Proton pump inhibitors (Tagamet and zantac), octreotide for hemorrhage vii. IV fluids viii. Low-fat diet ix. NG tube suction to remove gastric secretions 18. Tumors of the head of the pancreas a. 60-80% of pancreatic tumors occur in the head of the pancreas b. Obstruct common bile duct where the duct passes thru the head of the pancreas to where the duct passes thru the head of the pancreas to join the pancreatic duct and empty at the ampulla of Vater into the duodenum. c. Contributing factors i. Cigarette smoking ii. Exposure to toxins iii. High fat and meat intake iv. Chronic pancreatitis d. Clinical manifestations i. Jaundice ii. Clay-colored stools iii. Dark urine iv. Abdominal discomfort or pain v. Pruritus

vi. Anorexia and weight loss vii. Malaise e. Diagnosing i. ERCP identifies the cause ii. Collections of specimens iii. CT, MRI, ultrasound iv. Glucose tolerance test 1. Identify degree of damage to islet cells f. Medical mgt i. Before surgery 1. Liver and pancreatic function studies 2. High protein diet along with pancreatic enzymes 3. Adequate hydration 4. Correction of Prothrombin deficiency w/ vit K a. (synthesis of vitamin K) ii. Analgesics 1. Nonopioid 2. Antioxidants iii. Radiation therapy iv. Chemotherapy v. Surgery 1. Pancreaticoduodnectomy (Whipples procedure) a. For tumors of the head of the pancreas 19. Increased ICP clinical manifestations a. Early changes i. LOC ii. Mental status iii. Speech iv. Pupil response v. Extraocular movement vi. Unilateral weakness vii. HA b. Late changes

i. Abnormal posturing 1. Decerebrate towards the core 2. Decorticate opposite ii. Coma iii. VS (cushings triad) iv. Respiratory pattern v. Projectile vomiting vi. Loss of brain stem reflexes 1. Gag, cough, corneal, swallow, pupil, will have dolls eyes, periorbital edema, will become flaccid c. Complications i. Brain stem hernation ii. Diabetes insipidus 1. Results from decreased secretion of antidiuretic hormone (ADH) a. Excessive urine output b. Decreased urine osmolality c. Serum hyper osmolarity 2. Therapies a. Fluids b. Electrolyte replacement c. Vasopressin (desmopressin) (DDAVP therapy) iii. Syndrome of inappropriate antidiuretic hormone (SIADH) 1. Results from increased secretion of ADH. a. PT becomes volume overloaded b. Low urine output c. Serum sodium concentration becomes dilute. 2. Treatment a. Fluid restriction (<800 mL/day with no free water) b. In severe cases, careful admin of a 3% hypertonic saline solution may be therapeutic. 20. Medical management a. Decreasing cerebral edema i. Administration of colloid solutions 1. Mannitol

a. Can cross thru the blood-brain barrier 2. Fluid restriction a. Monitor I & O 3. Reducing CSF/IC blood volume a. Ventriculostomy (common in peds shunts going into the abdominal cavity) 4. Controlling fever a. Admin of antipyretic meds like Tylenol b. Cooling blanket (bear huggers) 5. Reducing metabolic demands a. Barbiturates b. Paralytics (drugs that will paralyze the PT and machines control the PT) 21. Intracranial surgery nursing interventions a. Maintaining cerebral tissue perfusion b. Regulating temp c. Improving gas exchange d. Managing sensory deprivation i. Periorbital edema 1. Impaired vision is a late sign e. Enhancing self-image i. Facial/periorbital edema ii. Hair shaved over operative area f. Managing potential complications i. All standard postoperative concerns ii. Bleeds, suture site, drainage (serousanguious) 22. Guidelines for seizure care a. During seizure i. Provide privacy if possible ii. Ease PT to the floor if possible iii. Protect head to prevent injury w/ a pad iv. Loosed constrictive clothing v. If PT is in bed, remove pillows and raise siderails vi. If aura precedes the seizure, insert an oral airway to reduce risk of PT biting tongue or cheek vii. Do not attempt to pry open jaws that are clenche

viii. Do not restrain PT ix. If possible, place PT on side to prevent aspiration b. After seizure i. Keep PT on one side ii. Typically a period of confusion after a grand mal iii. Short apneic period may occur during or immed after a generalized seizure iv. Reorient PT to environment on awakening v. If PT becomes agitated after seizure, use persuasion and gentle restraint to assist him or her to stay calm 23. Status epilepticus a. Series of generalized seizures w/out full recovery between attacks. Its a medical emergency! i. Increased metabolic demand 1. Energy expended during convulsions ii. Hypoxia and venous congestion 1. Irregular resps d/t convulsions 2. May lead to irreversible brain damage iii. Precipitating factors 1. Subtherapeutic medication level is the #1 cause 2. Fever and infection 24. Headache a. Primary HA i. One for which no organic cause can be identified. 1. Types a. Migraines, tension type, cluster ii. Migraine manifestations 1. Phases a. Prodrome (hours to days before) b. Aura (usually lasts <1 hour) c. HA (varies from 4 to 72 hours) d. Recovery 2. Severe, incapacitating HA 3. Photophobia 4. N/V

5. May be preceded by visual disturbances a. Aura 6. May be preceded by other SX a. Mild confusion, drowsiness, dizziness 7. Duration 4-72 hours a. In the prodromal phase b. Cluster HA manifestations i. Excruciating pain 1. Unilateral 2. Eye and orbit initially ii. Radiates to facial and temporal region iii. Affected side 1. Tears 2. Nasal congestion 3. Duration 15 minutes 4. May occur up to 8 x per day c. HA prevention i. Prevention 1. Avoid triggers a. stimulation b. stress c. foods i. caffeine ii. chocolate iii. tyramine iv. Chinese food ii. Medical mgt 1. Preventative therapy a. Medication taken routinely (prophylactic) i. Imitrex 1. Do not stop abruptly ii. Abortive therapy 1. Meds taken at or prior to onset

a. NSAIDS b. Tylenol c. Tryptivans i. Imitrex 2. Ischemic stroke a. CVA or brain attack is a sudden loss of function resulting from disruption of the blood supply to a part of the brain. b. Most common type i. Caused by thrombus 1. Forms at site of atherosclerotic plaque 2. Infarction distal to site 3. Degree of damage depends on size of vessel ii. May resolve in an hour: TIA c. Risk factors i. Nonmodifiable 1. Age >55 2. Gender a. More frequent in males 3. Race a. Incidence in Af Amer is double than in caucasions ii. Modifiable 1. HTN (esp uncontrolled HTN) a. More significant than all the others b. d/t weakening the blood vessels 2. Atrial fib 3. Hyperlipidemia 4. Diabetes 5. Smoking 6. Obesity 7. Alcohol abuse 8. Living in the stroke belt a. AL, AK, GA,KY, LA, TN, MS i. d/t southern cooking

25. Ischemic Stroke medical mgt a. Pharm (prophylactic) i. Anticoagulants know INR range!! 1. Atrial fib a. Coumadin ii. Platelet aggregation inhibitors 1. Plavix (prevents platelets from sticking together) iii. Statins (cholesterol reduction) 1. Watch out for rhabdomylosis 2. Take at night iv. Anti HTN meds b. Surgical i. Carotid endarterectomy ii. Removal of clot 26. Thrombolytic therapy a. Administration must begin over 1 hour b. IV administration over 1 hour c. Only used for ischemic stroke verified by CT scan d. Contraindications i. Risk for bleeding 1. INR>1.7 (Coumadin) 2. Platelet count <100,000 3. PT >15 ii. HTN 1. SBP >185 2. DBP >110 iii. Seizure activity iv. HX of intracranial disease 1. Neoplasm, AVM, ICH v. Other recent intracranial pathology 1. Stroke, brain injury, intracranial surgery 27. Therapy for patients with ischemic stroke not receiving T-PA a. Anticoagulant administratiin (IV heparin or low molecular-weight heparin)

b. Interventions include: i. Measures to reduce ICP 1. Administering osmotic diuretic (mannitol) 2. Maintaining PaCO2 w/in range of 30-35 3. Position to avoid hypoxia 28. Ischemic stroke nursing interventions a. Improving mobility and preventing joint deformities i. Flexion/adduction contractures 1. Extremity positioning as directed 2. Spints 3. Use of prone position a. 15-30 mins several times a day 4. ROM exercises 5. Early ambulation ii. Preventing shoulder pain 1. Turning/transfring a. Assist on unaffected side 2. Positioning 3. Sling 4. ROM exercises 5. Pharm therapy a. NSAIDS iii. Enhancing self-care 1. Avoid neglect of affected side 2. Assistive devices iv. Managing sensory-perceptual difficulties 1. Visual stim on unaffected side 2. Use head-turning v. Assisting w/ nutrition 1. Speech therapy a. Swallowing difficulties 2. Modified consistency 3. Enteral tube

a. Monitor their glucose 4. Attaining bowel and bladder control a. Intermit catch b. Scheduled toileting c. Fiber, fluids 5. Improving thought processes a. Cognitive, behavior, emotional b. Multidisciplinary mgt 6. Improving communication a. Speech therapy b. Written schedule c. Communication board d. Speak slowly to client e. Avoid multi-step instructions 7. Maintaining skin integrity a. Reposition q 2 hours b. Skin clean/dry 8. Improve fam coping a. Encourage use of avail. Support b. Communicate realistic expectations 29. The patient with a hemorrhagic stroke a. Assessment i. Nerologic 1. Decreased function is earliest sign of deteriorating condition a. Glasgow coma scale ii. Cardiovascular 1. VS, color, pulses iii. Respiratory 1. VS, O2 sat, color, lung sounds b. Interventions i. Optimize cerebral tissue perfusion 1. Implementing aneurysm precautions 2. Absolute bedrest

3. Minimize stimulation 4. Measures to manage ICP c. Monitoring and managing potential complications i. Vasospasm 1. HA 2. Change in LOC 3. Prophylactic meds a. Calcium channel blockers w/ spasm 4. Seizures a. Seizure precautions b. Prophylactic meds 5. Hydrocephalus a. Acute i. Ventriculostomy b. Subacute i. VP shunt (ventriculoperitoneal) c. Rebleeding i. HA, signs of Increased ICP ii. Manage BP 6. Hyponatremia a. Occurs in 30% of SAH cases b. Serum sodium level <135 c. Treated w/ hypertonic fluids d. PT may be evaluated for i. SIADH ii. Cerebral salt-wasting syndrome