Medical Surgical Nursing

Techniques Eliciting Major Reflexes (A) Biceps reflex. (B) Triceps reflex. (C) Patellar reflex. (D) Ankle or Achilles reflex. (E ...

Gerontological Considerations Important to distinguish normal aging changes from abnormal changes Determine previous mental sta ...

Eye Opening Spontaneous 4 To Voice 3 To Pain 2 None 1 Best Verbal Oriented 5 Confused 4 Inappropriate Words 3 Incomprehensible S ...

Chapter 61 Management of Patients with Neurologic Dysfunction Altered Level of Consciousness (LOC) LOC: is apparent in the pati ...

Postures Glasgow Coma Scale Decorticate and Decerebrate Posturing Abnormal posture response to stimuli. (A) Decorticate postur ...

Interrupted family processes Collaborative Problems/Potential Complications Respiratory distress or failure Pneumonia Aspirat ...

Maintaining Tissue Integrity Assess skin frequently, especially areas with high potential for breakdown Frequent turning; use ...

Sensory Stimulation and Communication Talk to and touch patient and encourage family to talk to and touch the patient Maintai ...

Pupillary changes and impaired ocular movements Weakness in one extremity or one side Headache—constant, increasing in intensit ...

ICP Monitoring Intracranial Pressure Waves Nursing Process: The Care of the Patient with Increased Intracranial Pressure— Diagno ...

Deficient fluid volume related to fluid restriction Risk for infection related to ICP monitoring Collaborative Problems/Potent ...

Intracranial Surgery Craniotomy: opening of the skull Purposes: remove tumor, relieve elevated ICP, evacuate a blood clot, cont ...

Preoperative Care: Nursing Management Obtain baseline neurologic assessment Assess patient and family understanding of and prep ...

Fluid and electrolyte disturbances Infection Seizures Planning Major goals may include: Improved tissue perfusion Adequate th ...

Suction or encourage coughing cautiously as needed (suctioning and coughing increase ICP). Humidification of oxygen may help ...

Specific Causes of Seizures Cerebrovascular disease Hypoxemia Fever (childhood) Head injury Hypertension Central nervous system ...

Nursing Care during a Seizure Provide privacy and protect the patient from curious onlookers. (The patient who has an aura [wa ...

Chapter 61 Nursing Process The Patient with an Altered Level of Consciousness Assessment Assessment of the patient with an alter ...

 Bowel incontinence related to impairment in neurologic sensing and control and also related to changes in nutritional delivery ...

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