NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Infectious Processes

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing; Brain Abscess

Focus topic: Medical–Surgical Nursing

Definition: Infectious process resulting in an encapsulated collection of pus usually found in the temporal lobe, frontal lobe, or cerebellum. May result from local or systemic infection. Primary cause often ear, tooth, mastoid, or sinus infection. May also be from a distant site like pulmonary infection, bacterial endocarditis, or skull fracture.

Assessment
A. Increased temperature unless abscess is walled off, in which case temperature can be subnormal.
B. Headache, anorexia, malaise, vomiting.
C. Neurological deficits relative to area involved (focal seizures, blurred vision, etc.).
D. Signs of increased intracranial pressure.
E. Weight loss.

Implementation
A. Observe neurological signs for alterations.
B. Decrease temperature.

  • Sponge bath.
  • Antipyretic drugs.
  • Cooling blanket.

C. Administer appropriate antibiotics for causative agent.
D. Prepare client and family for surgical intervention.
E. Provide appropriate postoperative care.

Medical–Surgical Nursing: Meningitis

Focus topic: Medical–Surgical Nursing

Definition: An acute infection of the pia–arachnoid membrane, usually as the result of another bacterial infection such as upper respiratory, otitis media, or pneumonia (may be viral). May result in a degeneration of nerve cells or congestion of adjacent brain tissue.

Assessment
A. Inflammation, infection, and increased intracranial pressure cause the cardinal signs and symptoms.

  • Headache, high fever, nuchal rigidity, and changes in mental status are first indications.
  • Later symptoms include nausea, vomiting, disorientation, muscle aches, and positive Kernig’s sign.

B. Observe for signs of meningeal irritation.

  • Brudzinski’s sign: Flexion of head causes flexion of both thighs at hips and knee flexion.
  • Kernig’s signs: Supine position, thigh and knee flexed to right angles. Extension of leg causes spasm of hamstring, resistance, and pain.
  • Nuchal rigidity.

C. Other symptoms may be severe headache, stiff neck and back, photophobia.
D. As illness progresses, lethargy, irritability, stupor, coma, possible seizures.
E. Diagnosis made by testing CSF obtained by lumbar puncture.

Implementation
A. Maintain patent airway—give oxygen as ordered.
B. Treat the infective organism—antimicrobial therapy by intravenous route for 2 weeks, followed by oral antibiotics.

C. Droplet isolation for 24 hours after antibiotic therapy is initiated.

  • Treat all secretions from nose and mouth as infectious.
  • Check nasal cultures for organism.

D. Treat increased intracranial pressure or seizures. (Mannitol may be ordered for cerebral edema.)
E. Control body temperature.
F. Provide adequate fluid and electrolyte balance—be aware of fluid overload, which can cause cerebral edema.
G. Provide bed rest and a quiet environment; sedate if needed. Do not give narcotics or sedatives that would interfere with neurologic assessment.

H. Prevent complications of immobility.

  • Raise head of bed 30 to 45 degrees—decreases ICP.
  • Reposition frequently and provide range-ofmotion exercises.

I. Relieve headache and fever with acetaminophen.
J. Maintain restful environment with dim lights to decrease photophobia.

Medical–Surgical Nursing: Encephalitis

Focus topic: Medical–Surgical Nursing

Definition: Severe inflammation of the brain caused by arboviruses or enteroviruses. Can be fatal. Diagnosed by CT, MRI, PET scan, and spinal fluid culture. Polymerase chain reaction (PCR) test is a laboratory method for detecting the presence and/or level of antibodies to an infectious agent in serum. It allows for early detection of herpes simplex virus (HSV) and West Nile encephalitis antibodies, substances made by the body’s immune system to fight a specific infection.

Assessment
A. Fever, headache, vomiting.
B. Signs of meningeal irritation.
C. Neuronal damage, drowsiness, coma, paralysis, ataxia.
D. Symptoms vary and depend on organism and area of brain involved.
E. Symptoms resemble meningitis but have a more gradual onset.

Implementation
A. Monitor vital signs frequently.
B. Monitor neurological signs for alterations in client’s condition.
C. Administer anticonvulsant medications such as Dilantin.
D. Administer glucocorticoids to reduce cerebral edema.
E. Administer sedatives to relieve restlessness.
F. Administer antiviral medications as ordered.
G. Manage fluid and electrolyte balance to prevent fluid overload and dehydration.
H. Position client to maintain patent airway and prevent contractures. Provide range-of-motion exercises.
I. Promote adequate nutrition through tube feedings, and parenteral hyperalimentation if necessary.
J. Provide hygienic care (e.g., skin care, oral care, and perineal care).
K. Provide safety measures if client is confused.

Medical–Surgical Nursing: Postpolio Syndrome

Focus topic: Medical–Surgical Nursing

Definition: A neurological condition caused by the polio virus that invaded the central nervous system decades earlier.

Characteristics
A. Risk of developing postpolio syndrome (PPS).

  • Risk manifests as people reach age 45–60 (35 years from the original polio infection).
  • Progresses over time but becomes a major risk if acute health problem develops.
  • Clients who had nonparalytic or “mild” polio are also at risk for developing PPS.

B. For original polio infection, see Pediatrics chapter, pages 742, 744, and 747.
C. Cause of PPS appears to be neuromuscular failure— chronic overuse of polio-damaged nerves and muscles together with normal aging process.
D. If no medical records are available, electromyographic testing will confirm diagnosis of PPS.

Assessment
A. Clinical manifestations of PPS.

  • Excessive fatigue.
  • Muscle weakness (both in muscles involved in original infection and those that were not).
  • Joint pain.
  • Breathing problems.
  • Impaired swallowing.
  • Intolerance to cold.
  • Inability to carry out activities of daily living.

B. Onset usually insidious; but with any sudden change in health status (severe illness or general anesthesia for surgery), onset may be sudden.

Implementation
A. No specific treatment for PPS.
B. Management is targeted at controlling symptoms, especially fatigue, weakness, and pain. Overexertion can worsen weakness and fatigue.
C. Promote pacing of activities to avoid feelings of fatigue.
D. Planning includes rest periods as well as learning to use assistive devices such as canes, scooters, and wheelchairs.
E. Adaptive equipment will help with self-care.
F. Physical therapy can support fitness and mobility in light of limitations.
G. Weight loss interventions are helpful if the client is overweight.
H. Management of client focuses on lifestyle modifications to conserve energy and to support maximal performance of activities of daily living (ADLs).
I. Rigorous and aggressive therapy used after initial polio infection is contraindicated during the postpolio period.
J. An interdisciplinary team approach is essential to manage the client.
K. Monitor for respiratory function.

  • Position for maximum chest excursion.
  • Monitor oxygen—may present risk if breathing based on hypoxic drive, not CO2.
  • Muscle-relaxing medications and narcotic analgesics may be life-threatening if respirations are depressed.
  • Assess for speech, swallowing, or respiratory difficulties. Take nursing measures to prevent aspiration. These are similar to those described for clients with Guillain–Barré syndrome.

L. Effective pain management through pharmacologic and nonpharmacologic approaches will help the client to remain active and achieve a greater sense of well-being.
M. Protection from the cold will aid in pain relief.
N. Surgery presents special risks.

  • General anesthesia not tolerated well—regional anesthesia is a better option.
  • Clients should not have nonessential surgical procedures performed.

O. Maintain blood volume, fluid and electrolyte balance (especially important to replace potassium after surgery).
P. Cold intolerance may present a special challenge for client undergoing surgery.
Q. Results of experiencing reemergence of symptoms:

  • Can be devastating to the client.
  • May impact psychological well-being.
  • May evoke a sense of fear, anxiety, and/or depression.

R. Nurse can help the client by active listening, providing information about PPS, encouraging participating in support groups, and helping client gain a sense of control through active participation in lifestyle modifications.

Medical–Surgical Nursing: Creutzfeldt–Jakob Disease

Focus topic: Medical–Surgical Nursing

Definition: Rare and fatal degenerative brain disorder that leads to dementia and, ultimately, death. It is thought to be caused by prion protein. Prions are small infectious pathogens containing protein but lacking nucleic acid.

Characteristics
A. Causes.

  • May be inherited (10%).
  • Clients who received human growth hormone prior to more stringent purification methods instituted after 1978.
  • Clients who receive corneal transplants or cadaver dural grafts.

B. Types.

  • Sporadic Creutzfeldt–Jakob Disease (CJD).
  • Familial CJD.
  • Acquired CJD.
  • Variant CJD (vCJD)—from infected beef; also called mad cow disease; found in Great Britain.

C. Incubation ranges from 4 to 20 years.

Assessment
A. There are no diagnostic tests to detect CJD. It is definitively determined by autopsy and examination of brain tissue.
B. Onset is gradual, with memory loss as first symptom.

  • Assess for memory loss progressing to global dementia.
  • Sometimes resembles other dementia-like brain disorders such as Alzheimer’s, but CJD disease usually progresses much more rapidly.
  • Other symptoms may include: personality changes, anxiety, depression, memory loss, impaired thinking, blurred vision, insomnia, difficulty speaking, difficulty swallowing, sudden, jerky movements.
  • Death may occur after a few months.

Implementation
A. Nursing care emphasizes safety, skin and mouth care, nutrition, and comfort.

B. Prevention focuses on both caution in handling body fluids (blood or tissue) from clients with this diagnosis and, for mad cow disease, not eating contaminated beef.
C. The U.S. Blood Bank implemented guidelines in 2000 that refuse blood from anyone who has lived in Great Britain for more than 6 months.

Medical–Surgical Nursing: Altered Blood Supply to Brain

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Brain Attack (Cerebrovascular Accident, Stroke)

Focus topic: Medical–Surgical Nursing

Definition: A sudden focal neurological deficit due to cerebrovascular disease; the most common cause of brain disturbances.
A stroke is a medical emergency. Prompt treatment is crucial. Early action can minimize brain damage and potential complications.

Characteristics
A. Causes.

  • Thrombosis.
  • Embolism.
  • Hemorrhage (extradural, subdural, subarachnoid, or intracerebral).

B. Risk factors.

  • Circulatory—atherosclerosis, hypertension, anticoagulation therapy, cardiac valvular disease, synthetic valve and organ replacement, atrial arrhythmias.
  • Diabetes.
  • Sickle cell disease.
  • Substance abuse.
  • Sedentary lifestyle.
  • Hyperlipidemia.
  • Polycythemia.
  • Use of oral contraceptives.

C. Interruption of blood supply to brain via carotid and vertebral–basilar arteries—causes cerebral anoxia.
D. Cerebral anoxia longer than 10 minutes to a localized area of the brain—causes cerebral infarction (irreversible changes).
E. Surrounding edema and congestion—causes further dysfunction.
F. Lesion in cerebral hemisphere (motor cortex, internal capsule, basal ganglia)—results in manifestations on the contralateral side.
G. Permanent disability unknown until edema subsides. Order in which function may return: facial, swallowing, lower limbs, speech, arms.

Medical–Surgical Nursing

Assessment
A. Generalized signs—headache; hypertension; changes in level of consciousness, convulsions; vomiting, nuchal rigidity, slow bounding pulse; Cheyne–Stokes respirations.
B. Focal signs—upper motor lesion in motor cortex and pyramidal tracts: hemiparesis, hemiplegia, central facial paralysis, language disorders, cranial dysfunction, conjugate deviation of eyes toward lesion, flaccid hyperreflexia (later, spastic hyporeflexia).
C. Evaluate general residual manifestations.

  • Memory deficits; reduced memory span; emotional lability.
  • Visual deficits such as homonymous hemianopia (loss of half of each visual field).
  • Apraxia (can move but unable to use body part for specific purpose).

D. Evaluate client for rehabilitative program.

Medical–Surgical Nursing

Medical–Surgical Nursing

Implementation
A. Initial nursing objective is to support life and prevent complications.
B. Give oxygen as needed. Begin at 3 L/min unless client has chronic obstructive pulmonary disease (COPD).
C. Maintain patent airway and ventilation—elevate head of bed 20–30 degrees unless shock is present— encourage lying flat in bed if possible (except for ADLs).

D. Monitor clinical status to prevent complications.

  • Neurological.
    a. Assess for recurrent CVA, increased intracranial pressure, bulbar involvement, hyperthermia.
    b. Continued coma—negative prognostic sign.
  • Cardiovascular—shock and arrhythmias, hypertension.
  • Apply elastic stockings or pneumatic compression stockings as ordered to reduce risk of deep vein thrombosis.
  • Lungs—pulmonary emboli.

E. Maintain optimal positioning during bed rest period—prevent contractures.

  • During acute stages, quiet environment and minimal handling to prevent further bleeding.
  • Upper motor lesion—spastic paralysis, flexion deformities, external rotation of hip.
  • Positioning schedule—2 hours on unaffected side; 20 minutes on affected side; 30 minutes prone, bid–tid.
  • Begin passive–active range-of-motion exercises, four to five times daily.
  • Complications common with hemiplegia—frozen shoulder (vulnerable to injury due to stroke-induced injury to muscles); footdrop, use footboard.

F. Maintain skin integrity: Provide skin care every 2 hours; special protocol for back, bony prominences,and skin.
G. Maintain personal hygiene: Encourage self-help.
H. Keep side rails up and safety straps on if required.
I. Promote adequate nutrition, fluid and electrolyte balance.

  • Encourage self-feeding with swallowing and assess if gag reflexes present.
  • Food should be placed in unparalyzed side of mouth.
  • Enteral feeding or gastrostomy feeding may be necessary.

J. Promote elimination.

  • Bladder control may be regained within 3–5 days.
  • Offer urinal or bedpan every 2 hours, day and night.
  • Diet should have roughage and fiber to encourage elimination and prevent fecal impaction.
  • Activity and exercises will stimulate elimination.

K. Provide emotional support.

  • Behavior changes as consciousness is regained—loss of memory, emotional lability, confusion, language disorders.
  • Reorient, reassure, and increase self-esteem by encouraging client. Establish means of communication.

L. Promote rehabilitation to maximal functioning.

Medical–Surgical Nursing

Medical–Surgical Nursing

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Medical–Surgical Nursing: Types of Stroke

Focus topic: Medical–Surgical Nursing

A. Ischemic stroke—thrombotic or embolitic.

  • Drug therapy—tissue plasminogen activator (tPA).
    a. Must be administered within 3 hours of the onset of clinical signs. Some stroke centers can administer IV up to 4.5 hours of the onset. Tissue plasminogen activator is also given intra-arterially up to 6 hours after onset.
    b. Timing of the administration of the med is the most critical factor.
    c. Screening includes:
    (1) Noncontrast CT or MRI to rule out hemorrhagic stroke.
    (2) Coagulation studies.
    (3) Screen for a recent history of a GI bleed.
    (4) Head trauma within the past 3 months.
    (5) Major surgery within the past 14 days.
    d. During drug infusion:
    (1) Monitor neurological signs to assess for improvement or for potential deterioration related to intercerebral hemorrhage.
    (2) Control of BP is critical during treatment and for 24 hours following.
  • Surgical therapy.
    a. MERCI retriever—MERCI stands for mechanical embolus removal for cerebral ischemia.
    b. During this procedure, which is used for ischemic strokes, a catheter with a coiled tip is placed directly into the blood vessel, allowing the physician to pull the clot out.

B. Hemorrhagic stroke.

  • Surgical decompression if needed.
  • Clipping, wrapping or coiling of aneurysm.
  • Medical therapy.
    a. Anticoagulants and platelet inhibitors are contraindicated.
  • b. Calcium-channel blocker Nimotop (nimodipine) is given to clients with subarachnoid hemorrhage to decrease the effects of vasospasm and minimize cerebral damage.
    (1) Must assess BP and atrial pressure (AP) prior to administration.
    (2) Hold if AP ≤ 60 beats/min or systolic BP ≤ 90 mm Hg, contact physician.
    c. Hyperthermia is treated with aspirin or Tylenol (acetaminophen).
    (1) Increase in body temp can increase brain metabolism and cause further brain damage.
    (2) Cooling blankets may also be used. Monitor client temperatures closely.
    (3) Maintaining temperature during the first 24 hours after a stroke is most important in preventing detrimental outcomes.
    d. Seizure prevention—5–7% of stroke victims have seizures.
    (1) Antiseizure drug such as Dilantin is given if a seizure occurs.
    (2) Seizure prophylaxis is recommended in the acute period after intracerebral or subarachnoid hemorrhage. In other types of strokes, it is not recommended.

Medical–Surgical Nursing: Cerebral Aneurysm

Focus topic: Medical–Surgical Nursing

Definition: A dilation of the walls of a weakened cerebral
artery leading to rupture from arteriosclerosis or trauma.

Assessment
A. Alteration in level of consciousness (LOC) may be earliest sign—monitor for subtle changes indicating a change in condition.
B. Suggest pupillary reaction, diplopia.
C. Slurred speech, drowsiness may be early signs LOC is deteriorating.
D. Hemiparesis, nuchal rigidity, headache.

Implementation
A. Establish and maintain a patent airway.
B. Closely monitor client.

  • Check for deteriorating condition—pulse, blood pressure, level of responsiveness.
  • Monitor respiratory status—reduced oxygen increases chances of cerebral infarction.

C. Place client on bed rest in semi-Fowler’s or side-lying position (elevate bed 15–30 degrees to promote venous drainage).
D. Turn and deep-breathe client every 2 hours.
E. Suction only with specific order.
F. Provide darkened room without stimulation (e.g., limit visitors and lengthy discussions).
G. Avoid any exertion or strenuous activity; provide range-of-motion exercises.
H. Provide diet low in stimulants such as caffeine. Restrict fluid intake to prevent increased intracranial pressure.
I. Monitor intake and output.
J. Monitor vital signs for hypertension or cardiac irregularities. Do not take rectal temperature due to vagal stimulation leading to cardiac arrest.
K. Observe for complications indicating rebleeding, DVT, or increased size of aneurysm.
L. Surgical therapy: aneurysm and hemorrhage.

  • Immediate evacuation of aneurysm-induced hematomas greater than 3 cm.
  • Clipping, wrapping, or coiling of the aneurysm to prevent bleeding—Gugliemi detachable coils (GDCs) provide immediate protection against hemorrhage by decreasing pulsation within the aneurysm.
  • Over time, a thrombus forms within the aneurysm. Plugging the weak, bulging section of the artery or fistula stops blood flow to the affected area and markedly decreases the risk of rupture.
  • Coils are designed to remain anchored within the aneurysm or fistula and do not require eventual removal.
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