Immune sys characteristics:
Doptimalnormal
1) exaggerated:killing good cells (everything)
Course Name: 3)suppressed:not killing enough
m e e
-
Ex: Chemo
patient
Possible Complications:2%
to 10%
Treatment/Medications:
Disease/Illness:
because the
Guillain-Barre Syndrome
mortality
usually due to complications (ventilation
related)
1) ventilator associated pneumonia
2) thrombus: not moving enough
A medical
emergency
airway will eventually
become compromised.
Medical
Management
ummmmm
1) Supportive Care: elective intubation (intubation
before
emergency)
ROM to
active
-Physical Therapy: passive or thrombus.
and
attack
autoimmune
muscle
Pathophysiology: An acute, progressive
Withis?
wasting
prevent
on the peripheralmyelin that surrounds the nerves. The
giving good antibodies
Immunoglobulm:
and thats why its attacking2)
immune sys. is exaggerated
of bad antibodies.
removal
3) Plasmapheresis:
3)UTIs: foley use
the blood,
the nerves. This will all cause a decrease in cranial
remove
where they
mmmmmmmmm
very invasive
and ascending weakness
out of the plasma, puts in
functions,
nerve
reflexes,
bad
the
parts
separate
of Guillain-Barre'
variant
Syndrome: and
-Miller-Fisher
at the toes and works all
and then push
the plasma substitute in the patient,
paralysis. (ascending:starts
in the
weakness
that
its
is
eye
The difference
in
in.
wake
back
could
the
blood
all
up
acute,
you
the way up.With this being
downward. This
muscles that begins to work
the morning with tingling feet and by the end of the day,
the
because
more
diaphragm it
one is
concerning
can progress all the way up to your head, and now
capacity machinein
is much closer.
(Qualat)
you are
on a
interventivevital
me
ventilator.
Signs/Symptoms: A Everyone can present
differently
1)Bilateral/symmetrical weakness and
paresthesia:numbness/tingling
legs at the
The overall cause is unknown,
Risk Factors:
Pathophysiology:
!
.
caused
is
mmmm
but
usually
them. When the
body
cant determine whats
it.Startthese
goodandWhatsbad
numbness/tingling,
are
blocked, depending
over hours, days, or 3-4 weeks.
cant move anything
3) flaccid paralysis:
of
D)autonomic disturbances: functioning
the organs leading to vitalsign changes
etc)
Hachycardia, bradycardia, hypotension,
of the
alterations
involvement:
nerve
cranial
5)
cranial nerves (absent or slow) the
weakness
reflexes as
2) Absent deep tendon
moves up
as the wealeness
7) Decrease in respiratory drive:
moves up, it will weaken the diaphragm, causir
the patient to need to be intubated.
decrease in reflexes,
in cranial nerves. The
and then eventually
impulses are slowed
on how the disease develops
and decrease
same time.
2) pain
by
infections disease that may have
occurred 1-3 weeks ago. (also with trauma,
surgery, immunizations, HIV) The myelin is
the cushion around the nerves that protects
a virus or
in both
Assessment
Findings:
What
your
priority?
1Airway/Breathing,intubation. Usually elective,
to
meaning, the patient isnt to the point
where they arent breathing, but we are
before the paralysis
going to intubate
hits the diaphragm.
Nursing Diagnosis:
start
and
-es:i):
and
2) circulation:Autonomic disturbances
symptoms
weeks. The signs
the changes in vital signs. IV meds
theres no progression.
causing
to weeks where youre not
several
days
2) Plateau:
for treatment be it will start working
better, but youre also not getting
any
getting
quicker and be out of the system quicker.
worse.
3) Recovery: For months years, the myelin can start 3) Frequent neuro assessments to gauge how
to regenerate and grow back. Patient is improving patient is
progressing, turning every 2 hours,
Meagan Dahlby | [SCHOOL]
and
probably doing daily PT.
SCDs, bloodthinners to prevent clots, foley care
The event"(illness) usually occurs 1 4
12
-
I
-
4)communication: Patient will be cognitive, but
they cant more or
tie
speakableto
es !
is
with we below 12 will
to
due
be ineffective
diaphragm paralysis.
cardiac:continuous cardiac monitoring.
administration, fluids BP
IVLabs/Diagnostics:
drug⑤
-°-=
Applying or to anyone
3)Mobility:
passive/active ROM, turning q2hrs
4)Pain: IV pain management
"
for yes or no
5)communication: "Blink
a) Nutrition: tube feedings, TPN,
assess
swallowing
forthe
4absDiagnosticsthere ishasingletestprotein
Patient Goals:
⑤>>
mee
1) Lumbar puncture: could show elevated
completely normal
2)Nerve conduction studies: will be decreased
3) MR1/CT: rule out brain abnormalities) tumor,
hemorrhage) will appear normal for GB
could be
or it
ummmmmm
and
progressing.
be inhaled
can
teamawathatnot good. G
-
patients.
Patient Education:
pes: Myasthenic Crisis:
Cholinergic Crisis
Course Name:
Ion separate concept I
maps
Possible Complications:
1Aspiration: impaired swallowing
2) Respiratory compromise:generalized
weakness
Treatment/Medications:
Disease/Illness:
Medical
inhibitors,
17 Medications:cholinesterase
corticosteroids
(Prostigmin),
Myasthenia Gravis
neostigmine
(Quizlet card)
/immunoglobulins): improvement
last 28
2) IVIG
happens in
disorder that
Pathophysiology: chronic autoimmune
affects the neuromuscular junction. (Where the
neuron and muscle fibers connect. If the connection
is impaired or does not exist, it will interfere with
muscle function.
NeUVON -8
Management
e
mene
days
only
a few days But
lasmsahet restinPressSheetthe
the
1)Thymectomy: removal of3 thymus
for
antibodies are blocking
·the connection between the
muscle and neuron.
The
years
But may take up to
from
procedure
the patient to benefit
gland
*The overall goal is to get the patient
on the PO form of mostigmine
IVIG or plasmapheresis is usually only
given if the myastenia gravis puts the
(Prostigmin)
MUSCI
motor disorder, so
theres no affect on sensation or coordination.
patient in the hospital.
1) Initial symptoms:occular related
Labs/Diagnostics: 1) Ache antibodies: positive
diplopia(double vision) and ptosis) drooping
2) Tensilon Test: IV Tensilon is given and if
eyelids)
then myasthenia Gravis
symptoms improve,
movements
have
Atropine ready wrin
Must
2) Abnormal/Involuntary
Signs/Symptoms: A only a
-
Risk Factors:
3) Weakness of facial muscles, swallowma
(dysphonial, and
Daspiration), voice impairmentweakness
all over)
generalized weakness (muscle
symptoms will worsen with
sustained muscle use. (Ex: in the morning the
4)Signs and
patient
will be at their
is diagnose.
administering.Tensicattheintentes
be
3)Neuromuscular stimulation test? Will
isnt
decreased. Neuromuscular sys
like it should be
strongest)
firing
Patient Goals:
)Teach on the import
Assessment Interventions
Findings:
Ning
mmmmmm
at the same
tance of
Nursing Diagnosis:
taking medication everyday
time and / or 30-40mm before meals.
(pweakness)
2)Teach sis of exacerbatic
3) Energy conservation: don't want to worsen
symptoms. Space ADLs.
↳) Reducing aspiration: meds before meals and
eat, suctioning
rest before eating. Sitting up to
at bedside.
5)Avoid stress:infections: hand hygiene,
Meagan Dahlby | [SCHOOL]
avoid large crowds
2) Avoid vigorous physical activity
1) Avoid high environmental temperatures: puts
stress on the body.
Patient Education:
T
Course Name:
Treatment/Medications:
Disease/Illness:
Myasthenia Gra
1 Immediate
and IVIG. (immunoglobulins)
Myastenic Crisis
Possible Complications:
Pathophysiology: under
viral
Signs/Symptoms:
via IV.
medication, infection, or
illness can cause a
myasthenic
crisis.
1) Dysprea
2) Decreased vital capacit
3) Dysphagia
Risk Factors:
4) Dysarthria (slurred speech)
5)pAsusis
a blurred vision
prominent muscle weakness
8) tachycardia
9) pale, cool skin
10) voluntary muscles are flaccid from
the eyes N the bowels.
9 leVenteetion
me
en
Bipap and intubation.
e) Identify the cause: CBC, CXR, Bex3,
Urine:sputum as gram stain,
Broad Spectrum AB to find the
possible infection.
B Plasmaphoresis and IVIG
4)Steroids
5) NGT if patient cant swallow
Labs/Diagnostics:Tensilon
crisis, then muscle weakness will
weakimprove. If cholenergic, muscle
ness will increase. Prepare for
intubation.
Patient Goals:
Patient Education:
Meagan Dahlby | [SCHOOL]
Test: differentiate
between myasthenic vs. Cholenergic.
Atropine on hand. If it is a mysteric
Assessment Findings:
Nursing Diagnosis:
plasmaphoresis
Course Name:
Possible Complications:
Treatment/Medications:
Disease/Illness:
Myasthenia Gr:
Cholinergic
Pathophysiology:
gravis
Crisis
over medication of
myasthenia
medication. (anticholinesterase)
1) Atropine for bradycardia and
respiratory distress (Tensilm
effect)
2) Dont administer anymore
anticholinesterase drugs.
Norsing Interventions
un
is protect
Risk Factors:
airway: Bipap and
intubation
2 NG if patient cant swallow
A No culture studies be this didnt
Signs/Symptoms: 1) increased muscle weakness
happen be of an infection. Waiting
within 1-2 hours of administration of
for meds to wear off.
anticholinesterase drugs
Labs/Diagnostics: Tensilon Test: differentiate
2) NIV
between myasthenic vs. Cholenergic.
3) abdominal cramps
Atropine on hand. If it is a mysteric
4) increased respiratory secretions
crisis, then muscle weakness will
(1) decreased vital capacity
Ediarrhea
weakimprove. If cholenergic, muscle
12)
a) diaphoresis
dysphagia
ness will increase. Prepare for
isI
dysarthria
bronchospasm
intubation.
8) hypotension 14) ptosis
a) bradycardia is)blurred vision
Patient Goals:
10) dyspnea
Assessment Findings:
Patient Education:
Nursing Diagnosis:
Meagan Dahlby | [SCHOOL]
(ALS]
Amyotropic Lateral Sclerosis
"Lou
Course Name:
Possible Complications:
Gehrig's
Disease/Illness:
Disease"
Pathophysiology: Loss of nerve cells controlling muscles
atrophy
causing progressive weaknessofand
extremities and
muscle
of
the
Idegeneration)
muscles are
all
voluntary
trunk. Eventually
is paralyzed but
and
the
patient
affected
sensation and mind are still intact.
Signs/Symptoms:
Initial complaints
symptomatic
3)difficulty
swallowing
only one side of the body is affected
Eventually
paralyzed
3)Antidepressants due to quality of
2) Laxatives the body
life
4)Nutrition will eventually need a
-
feeding tube
5) Tracheostomy
2) Prevent DVT
7) Prevent skin breakdown
8) Living Will-patientwill determine
what required interventions they want
and dont want.
Labs/Diagnostics:
1) Clinical manifestations. Theres
usinglettesttodiagnosPhysical multie
other test to rule out other conditions.
the disease
progresses.
Patient Goals:
Assessment Findings:
Patient Education:
Nursing Diagnosis:
Meagan Dahlby | [SCHOOL]
is
-
sides of the body will be affected
my
as
relaxer
-
me
4)slurred speech
5)maybe
relief
1) Baclofen-muscle
17 muscle cramps
2) weakness
Risk Factors:
A Focusing on
Treatment/Medications:
Disease/Illness:
⑦@°@°
Course Name:
Menigitis (viral:fungal I
Possible Complications:
Pathophysiology: viral:
a viral illness
most common that follows
Fungal: two different strands. Cryptococcal
herformans:fulminant fungal sinusitis (
·
Treatment/Medications:
Viral
* treatment is based on
beamassbacteritin
ruled out. (Antibiotic treatment)
will be ruled out
Bacterial
meningitis
-
via CSF culture.
2) Full recovery is expected
Fungal
m
Inflammation of the menuges that
line the brain and spinal cord.
Risk Factors: Holder
immune sys
adults/infants:
2) immunosuppressed
3)Dense communities:college dorms,
projects
military bases, housing
potitis media leat infection): close
to the brain
mastoiditis
5)
b) acutel chronic sinus infection
2) sickle cell anemia
8) penetrating trauma
9) open brain surgery
1) Medications I Amphotericin B-IV
and Flucytosine)
2)Treat symptoms (antipyretics
Signs/Symptoms: Viral is no exudate found in
2) Self limitingmum CSF (no bacterial
and corticostewids)
patient does what- 3) fever 21) headache
3) Antibiotic treatment until
Labs/Diagnostics:
(light sensitivity(
bacterial
°@*
meningitis iS ruled cut.
gerttobia
(muscle pain)
-
a) myalgia
7) nausea
8) nuchal rigidity (stiff neck)
Fungal
m
isfever
e) headache
3) N/V
Patient Goals:
Assessment Findings:
10) tongue piercing
Patient Education:
Nursing Diagnosis:
Meagan Dahlby | [SCHOOL]
1) Droplet isolation
levenviral and fungal)
Initial Assessment
Treatment/Medications:
Disease/Illness:
Course Name:
Bacterial Meningitis
Possible Complications:
evention
e
me
1) History: Trauma? Living enviroment?
i) vaccinations:pneumonia and flo
Istreptococcus pneumonial and
Ademopphilius influenza (HIB)
2) Aggressivetreatment for respiratory,
ear, and sinus infection
3)Prophylactic treatment to those
exposed rifampin (ciproflaxial
-
ceftriaxone
or
Of
H. influenza (HIB)
Pathophysiology:
Medical
emergency and highly
100% mortality if left untreated,
Bacteria enters the bloodstream because of
an infection, injury, or procedure that crosses
the blood brain barrier and gets into the spinal
fluid causing inflammation of the meninges and
cerebral tissue. Increase in ICP (change in LOC,
contagious.
Making sure to treat those that
close proximity.
2) Complete neuro assessment: Focusing
on cranial nerves, assessing for sepsis,
sis of PICP, seizure precaution due to
were in
mmm
meningeal irritation.
Medical
Management
in
noun
1)Droplet isolation
Takes cultures
back
days to come
Broad spectrum antibiotic that crosses
pupil changes, etc) 2)blood
brain barrier(penicillin, CephalosporinC
1)
3)corticosteroids dexamethasone. Aswelling
Signs/Symptoms: Initial: headache and
Dosmotic Divretic mannitol (b(CP)
fever
5) Antiepileptics for seizures
a nuchal rigidity: stiff neck and difficult
Labs/Diagnostics:
to flex
headache, blurry vision, NIV,
-
-
Risk Factors:
3)Positive
presentswithlaceMRIfirstfanatientsthe
Kernig's sign
A positive Brudzinski's sign
2) Lumbar puncture (CSF
5)Photophobia
ridigidity
and fever
(BC(PWBC), electrolytes, cultures
ICSF, blood, vine, wounds, etc)
4) Gram stain (swab) of urine, throat, nose
3)Labs:
b) rash
isis of increased ICP
Patient Goals:
Assessment Findings:
interventions
using
mmm
Nursing Diagnosis:
Dobtain specimen before initiating
antibiotics
2) start antibiotic therapy Within 1-chrs
3)vascular assessment 94hrs(sepsis)b
perfusion (pulses)
4) Pain management for severe headache
-
I
Opioids
5) Active and passive ROM
Meagan Dahlby | [SCHOOL]
analysis): nuchal
Patient Education:
Course Name:
Possible Complications:
Disease/Illness:
Encephalitis
Treatment/Medications: Medical
Management
1) Acyclovir: HSV. Imed card)
2) symptom management for vector
borne and antifungal for fungal in-
immi
fection (amphotericin)
Pathophysiology: An acute inflammatory process
of the brain tissue that may be caused by
a viral infection (herpes simplex), vector
borne infection (West Nile, St. Louis) and
fungal infection.
Signs/Symptoms:
2) fever
D) headache
3) confusion
Risk Factors:
4) change in LOC
5) flaccid paralysis
El photophobia
Labs/Diagnostics: ICT/MRI:
inthe
brain
Assessment Findings:
Patient Education:
Meagan Dahlby | [SCHOOL]
swelling
2) Analyse CSF:may not have any
alterations, but may be able to trace
the viral infections
Patient Goals:
Nursing Diagnosis:
show
Course Name:
Possible Complications:
Promptly treating
ention:
num
1) Otitis media
2) mastoiditis
3) Sinusitis
4) dental infections
Disease/Illness:
Brain Abscess
Pathophysiology: collection
of infectious material
commonly from
with brain tissue most
bacteria.
Treatment/Medications:
Medical
Management
me
1) Control ICP
(mannitol)
2) Drain abscess
3) corticosteroid to treat cerebral
edema
5) Any other systemic infection
Signs/Symptoms: headache
worse in the
Risk Factors:
2) fever
3) vomiting
morning
that is usually
4)neurologic deficits
5)sis of increased ICP (altered Loc and
Seizures)
Labs/Diagnostics: DCT/MRI:
abscess
2) GT guided aspiration to obtain and
identify causative organism
Patient Goals:
Assessment Findings:
Patient Education:
Nursing Diagnosis:
Meagan Dahlby | [SCHOOL]
will show the