NURS 443 Lecture Notes - Lecture 3: L-Dopa, Pituitary Gland, Depth Perception
Exemplar
Types
Assessment
Treatment
Meds
Interventions
Seizure
General (tonic,
clonic, absence,
myoclonic,
atonic/akinetic),
Focal (complex
& simple),
Unclassified
General: tonic-clonic phases, aura
before seizure, hypoxia, biting of
cheek/ tongue, incontinence,
confusion/ sleepiness my occur
Focal: may have consciousness or
ot. Tpiall epeiee sleepig
spell
Vagal nerve
stimulator, surgical
removal or
interruption of brain
tissue
• Phenytoin (Dilantin)
• Pregabalin (yrica)
• Lorazepam (Ativan)
• Diazepam (Valium)
• Carbamazepin
(Tegretol)
• Levetiracetam (Keppra)
During: keep patent airway, do not
obstruct mouth, loosen tight clothing,
do not restrain, turn on side to
prevent aspiration, protect from
hitting things
Post: check vitals, assess for injuries,
perform neuro check, turn light off, do
not overstimulate, put padding on side
rails, leave bed low, document seizure
Stroke
TIA, Ischemic
(thrombotic,
embolic),
Hemorrhagic
(intracerebral,
subarachnoid)
Left: Agnosia, Aphagia, Alexia,
Agraphia, right extremity
hemiplegia, slow behavior, mood
swings, loss of vision
Right: one-sided neglect syndrome
(ignore one side of body), loss of
depth perception, left sided
hemiplegia
Ischemic: Stent,
MERCI
Hemorrhagic:
clipping of aneurysm
TIA: Bypass, stent,
angioplasty, carotid
endarterectomy
• tPA (Retavase)
• Heparin or Warfarin
• Aspirin
• Nimodipine (Nimotop)
• Monitor vitals every 1-2 hrs
• Provide Oxygen therapy
• Check LOC
• Put on heart monitor
• Elevate head of bed
• Assist with communication skills
• Assist with feeding
• Assist with moving and ROM
• Prevent DVT
Brain
trauma
Diffuse
(Concussion &
DAI)
Focal
(Lacerations,
Contusion,
Hematoma)
Skull fracture or
laceration
• Irritable, decreased LOC, Amnesia
• Dilated/ pinpoint/asymmetric
pupils
• Cheyne-Stokes respirations
• decerebrate/decorticate/flaccid
posture
• CSF leak from nose or ear
• Peioital ehosis o Battle’s
sign
• Severe headache
Skull fracture:
craniotomy and
cranioplasty
Concussion: observe
and monitor ICP
Hematoma: blood
must be removed
and craniotomy done
• Mannitol (Osmitrol)
• Pentobarbital
(Nembutal Sodium)
• Phenytoin (Dilantin)
• Morphine Sulfate
• Assess GCS, Nerve function, pupils,
respirations, LOC, ICP
• Monitor for infection
• Elevate head of bed and prevent
movement of head
• Monitor fluid and electrolytes
• Prevent coughing, sneezing, and
straining
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Document Summary
General: tonic-clonic phases, aura before seizure, hypoxia, biting of cheek/ tongue, incontinence, confusion/ sleepiness my occur. Vagal nerve stimulator, surgical removal or interruption of brain tissue. Agraphia, right extremity hemiplegia, slow behavior, mood swings, loss of vision. Right: one-sided neglect syndrome (ignore one side of body), loss of depth perception, left sided hemiplegia. Tia: bypass, stent, angioplasty, carotid endarterectomy: phenytoin (dilantin, pregabalin (yrica, lorazepam (ativan, diazepam (valium, carbamazepin (tegretol, levetiracetam (keppra, tpa (retavase, heparin or warfarin, aspirin, nimodipine (nimotop) Skull fracture or laceration: irritable, decreased loc, amnesia, dilated/ pinpoint/asymmetric pupils, cheyne-stokes respirations, decerebrate/decorticate/flaccid posture, csf leak from nose or ear, pe(cid:396)io(cid:396)(cid:271)ital e(cid:272)(cid:272)h(cid:455)(cid:373)osis o(cid:396) battle"s sign, severe headache, mannitol (osmitrol, pentobarbital (nembutal sodium, phenytoin (dilantin, morphine sulfate. Hematoma: blood must be removed and craniotomy done. During: keep patent airway, do not obstruct mouth, loosen tight clothing, do not restrain, turn on side to prevent aspiration, protect from hitting things. Persistent headache, lethargy, mood swing, short attention span, decreased short-term memory,
