Medical-surgical Nursing Demystified

(Sean Pound) #1

(^252) Medical-Surgical Nursing Demystified
to pain 2
none 1



  • Motor responses obeys commands^6
    localizes pain 5
    withdrawal (normal) 4
    abnormal flexion 3
    extension 2
    none 1

  • Verbal responses oriented^5
    confused conversation 4
    inappropriate words 3
    incomprehensible sounds 2
    none 1

  • Monitor for signs of increased intracranial pressure—diminished level of con-
    sciousness, headaches, restlessness, confusion, nausea and vomiting, speech
    changes, or seizures.

  • Notify healthcare provider of changes in neurologic status.

  • Develop a means of communication with the patient—aphasia may compro-
    mise use of call bell system or intercom.

  • Assess for neglect syndrome—patient may act as if unaware of the side
    affected by paralysis due to the stroke.

  • Need for rehabilitation to return to prior functional ability.

  • Explain to the patient:

  • Home care needs.

  • Proper technique to transfer from bed to chair.

  • Use of ambulatory assist devices: cane, crutch, walker.

  • Special dietary needs; use of Thick-it®for liquids.

  • Medication schedule, use, side effects, and interactions.


Seizure Disorder


WHAT WENT WRONG?


This is a disorder that involves a sudden episode of abnormal, uncontrolled dis-
charge of the electrical activity of the neurons within the brain. The patient may
experience a variety of symptoms depending on the type of seizure and the cause.

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