Harding: Critical Thinking Cases in Nursing, 7th Edition (2024)

1.What is PD?

PD is a chronic, progressive neurologic disease associated with the degeneration of the dopamine-producing neurons of the substantia in the midbrain, which enables us to move fluidly and smoothly. The cause is not known. Once cell loss reaches 80%, manifestations appear. The onset of PD is gradual and insidious, with steady worsening of motor function as time progresses.

2.What is parkinsonism?

It is a syndrome that consists of slowing down in initiating and executing movement (bradykinesia), increased muscle tone (rigidity), tremor, and impaired postural reflexes.

3.What are the clinical manifestations of PD? Underline the symptoms L.C. has mentioned.

Increased muscle rigidity, jerky “cogwheel” motion; masklike face with blank facial expression; inability to blink; drooling, decreased gag reflex, inability to chew or swallow; unintentional tremor, “pill rolling” at rest which stops with the initiation of intentional movements; general weakness and muscle fatigue; restlessness, compelling need to ambulate; dysphagia; loss of postural reflexes; stooped, shuffling gait; autonomic manifestations include diaphoresis, seborrhea, postural hypotension, decreased libido, GI hypomotility, urinary retention; high-pitched, monotone voice; reduced or absent arm swinging on one or both sides of the body when walking; micrographia (change in handwriting or handwriting gets smaller)

4.L.C.’s wife asks you, “How do the doctors know he really has Parkinson disease? They never did a lot of tests on him.” How is PD diagnosed?

There are no diagnostic tests specific for PD. The diagnosis is based on the patient’s history and interpretation of a range of clinical findings (TRAP: tremor, rigidity, akinesia, and postural instability). The only definitive proof of PD is dopamine cell loss and eosinophilic cytoplasmic Lewy bodies which can only be found at autopsy. Therefore, a positive response to antiparkinsonian medications (levodopa or dopamine agonist) provides confirmation of PD.

5.L.C. asks, “Why don’t they give me a dopamine pill? Wouldn’t that just fix everything?” Why is oral dopamine not a replacement therapy?

Dopamine is not given orally because it is metabolized to inactive substances before reaching the brain. Levodopa is given instead because it is the metabolic precursor of dopamine. It crosses the blood-brain barrier and restores dopamine levels in the brain.

6.Why is levodopa given in combination with carbidopa?

Carbidopa, on its own has no therapeutic effects. But, in combination with levodopa, Carbidopa prevents the peripheral metabolism of levodopa; therefore, less levodopa is needed which in turn decreases the side effects of levodopa.

7.Why did L.C.’s dyskinetic movements appear to be worse just after taking carbidopa-levodopa? What changes to his medication therapy may be needed?

After prolonged treatment, side effects such as dyskinesia may occur, and the medication’s effectiveness decreases. One option is to decrease the medication. Hospitalization for a “drug holiday,” during which all drugs are stopped for a time may help. The drugs are then restarted, often with smaller doses producing favorable results.

8.Because L.C. takes Sinemet, what serious adverse effect should you assess for in him?

1. Suicidal thoughts
2. Permanent hearing loss
3. Steven-Johnson syndrome
4. Spontaneous tendon rupture

9.L.C.’s wife asks, “They can do surgery for everything else. Why can’t they do some kind of surgery to fix Parkinson disease?” How would you describe the surgical treatments available for patients with PD?

Surgical intervention, including ablation (e.g., thalamotomy, pallidotomy), deep brain stimulation (DBS), and stem cell transplantation are reserved for those who do not respond to medications. DBS involves electrical stimulation of dopamine-deficient brain tissues in a way that helps reduce abnormal movements. Unlike ablation procedures, which are permanent, it can be adjusted to control symptoms better and is reversible. Fetal neural tissue transplants into the basal ganglia are meant to place dopamine-producing cells in the brains of PD patients. This therapy is still in experimental stages and involves many ethical issues.

10. What interprofessional team members would be involved in L.C.’s care and how?

Patients often benefit from referrals for speech therapy, OT, and PT to evaluate and treat swallowing, communication, and functional abilities. The speech therapist can diagnose dysphagia, recommend the safest head position for eating, and recommend the ideal food texture and liquid consistency to prevent aspiration. OT decides whether any adaptive feeding devices are necessary to promote independent eating. PT will evaluate physical abilities and recommend exercises and techniques to combat PD symptoms and decrease fall risk so that L.C. can stay as active, safe, and independent as possible.

11. What factors do you need to take into consideration when helping L.C. with these referrals?

You need to figure out what type of health care coverage L.C. has and which providers accept his health care coverage. Do L.C. and his spouse have any personal preferences? Evaluate the network providers and decide if working with PD patients is within their area of expertise. What is the provider’s availability? Is the provider accepting new patients? How far is the office from L.C.’s home? What are the office hours? Will there be any out-of-pocket fees?

12. L.C. is reporting an increase in drooling, and you are concerned about his ability to swallow. What further assessment could you perform to determine whether L.C. is at immediate risk for aspirating?

Is there any facial drooping or difficulty chewing or swallowing? Is he reporting any difficulty swallowing or complaining of something sticking in the throat? Does he cough, choke, or drool when eating? Does he complain of hoarseness or dry throat? Does his voice sound wet or gurgling? Does he store food in the cheek pockets? Is the gag reflex weak or absent? Can he close his lips? Does he experience problems with any specific foods or fluids? Has he had to try any accommodation for feedings?

13. What are 3 nutrition interventions that should be implemented for L.C.?

Verify that dentures fit properly and that good oral hygiene is maintained. Encourage rest periods before meals. During mealtime, allow an adequate amount of time to eat. Position him with his head upright and the chin flexed slightly forward to help with swallowing. Start with small amounts of food. Place foods into the unaffected, or stronger, side of the mouth. Stimulate swallowing by stroking the side of the neck, and support the weakened side if appropriate.

14. Because L.C. is reporting that his gait is more unsteady, there is an increased risk for falls. Which suggestion could you offer to diminish this risk?

1. Only use a wheelchair to get around
2. Use a bag or backpack to carry objects
3. Stand as upright as possible and use a walker
4. Keep the feet close together while ambulating

15. What are 3 suggestions you can make to L.C. to help manage fatigue?

Tell him to keep track of times during the day when akinesia is better and his medications are working well; these are the times to perform energy-consuming tasks because this is when movement is easier. Tell him to pace himself and allow for periods of rest. He needs to keep active—those who exercise daily experience less fatigue. A short nap after lunch is helpful; tell him not to sleep frequently throughout the day because this will inhibit nighttime sleeping and increase daytime fatigue.

16. You are giving instructions to L.C. and his wife about ambulating safely. You determine that they understand the directions if they say that L.C. will:

1. Schedule his PT appointments in the evening
2. Sit on a large, soft sofa with supportive pillows
3. Use a step stool to obtain difficult-to-reach items
4. When rising from a seat, rock back and forth to start moving

17. As L.C.’s case manager, identify 5 things that you would need to assess to determine whether L.C. could be cared for in his home.

Social support system; layout of home, including number of stairs and presence of handrails, proper lighting, presence of loose carpeting, throw rugs, or other items that might cause falls, location of bathroom, tub, or shower; available safety devices; transportation; meals and available help with cooking; delivery of meals into home

1.What role do diagnostic tests play in evaluating N.T. for a suspected CVA?

Noncontrast CT scan is the primary test used to diagnose a CVA. CT can indicate the size and location of the lesion and differentiate between ischemic and hemorrhagic CVA. For optimal results, it should be done within 25 minutes and read within 45 minutes of arrival at the ED. If the CVA is ischemic and less than 3 hours old, the CT will appear normal. N.T. has a history of AF; an ECG will be necessary to evaluate rhythm status. An echocardiogram would help evaluate for thrombi in the atria or ventricles. A carotid ultrasound is used to identify any atherosclerotic plaques.

2.Explain how knowing the type of CVA is an important factor in planning care.

The medical management varies by CVA type. An ischemic CVA, caused by cerebral artery occlusion from a thrombus or embolus, can be treated by anticoagulants and/or fibrinolytic therapy, which are contraindicated in a patient with a hemorrhagic CVA.

3.Which factor in N.T.’s history is the most likely contributor to her having a CVA and why?

AF is link to an increased CVA risk. With atrial fibrillation, there is not synchronized atrial contraction, so blood is not forced into the ventricle at the end of diastole as it is in normal sinus rhythm. This leads to decreased atrial kick, decreased preload, and stagnant blood within the atria. This combination leads to thrombi formation and increased risk of embolization to the cerebral circulation. Studies have shown that patients with AF should be on chronic anticoagulation.

4. The primary factor influencing the manifestations of a CVA is the:

1. Area of the brain affected
2. Speed of onset of the CVA
3. Amount of brain tissue affected
4. Type of CVA the patient experienced

5.What are the common manifestations of a CVA?

Weakness or numbness of one side of the face or body; facial drooping; difficulty swallowing; ataxia, clumsiness; double vision; slurred speech; aphasia; severe headache; hypertension; altered heart rate; changes in affect, memory, or judgment; nausea and vomiting; altered LOC, confusion, or agitation; problems with respiratory function or gag reflex

6.How should you position N.T.?

Elevate the head of the bed 30 degrees and position her head to one side to prevent aspiration of secretions. Raise the side rails.

7.Outline the focused assessment you need to obtain.

Assess airway, ability to clear secretions, VS, and ECG. Assess LOC. Complete the Glasgow Coma Scale. Assess pupil reaction, EOMs, vision, and facial symmetry. Determine her ability to speak. Evaluate the movement and strength of all 4 extremities.

8.Complete the National Institutes of Health Stroke Scale (NIHSS) scores for each of N.T.’s symptoms.

9.Based on your scoring, what level of CVA did N.T. experience?

N.T. scored a 12, which places her CVA in the “moderate” CVA category.

10. There are a number of manifestations of a CVA. Match the description of various losses with the term describing the loss:

Correct answers are: A. 5; B. 4; C. 2; D. 3; E. 7; F. 6; G. 1.

Chart View

Physician’s Orders

IV 0.9% NaCl at 75 mL/hr
Activase (tPA) per protocol
Stat CBC, PT/INR, CPK isoenzymes
Neurologic assessment every hour
Obtain patient weight
VS every hour
O₂ at 2 L per nasal cannula (NC)
NPO until swallowing evaluation

11. Outline a plan of care for implementing these orders.

Maintaining a patent airway is essential to support oxygenation and cerebral perfusion, so first place N.T. on O₂. Then, because the tPA dose is based on N.T.’s weight, obtain an accurate weight. After obtaining the weight, draw the lab work and start the IV infusion. Obtain the baseline neurologic assessment and VS before starting the tPA infusion. Place N.T. on NPO status.

12. Which interventions can you delegate to the UAP? Select all that apply.

1. Obtaining N.T.’s weight
2. Obtaining a manual BP per protocol
3. Initiating O₂ therapy by nasal cannula
4. Assisting N.T. in repositioning every 2 hours
5. Performing N.T.’s neurologic checks every hour

13. What is the purpose of monitoring the CK isoenzyme levels?

CPK-BB isoenzyme elevation after a CVA indicates brain tissue injury and/or infarction.

14. The instructions on the tPA vials read to reconstitute with 50 mL of sterile water to make a total of 50 mg/50 mL (1 mg/mL). The hospital protocol is to infuse 0.9 mg/kg over 60 minutes with 10% of the dose given as a bolus over 1 minute. N.T. weighs 143 pounds. What is the amount of the bolus dose, in both milligrams and milliliters, you will give in the first minute? What is the amount of the remaining dose you will need to give?

N.T. weighs 65 kg (143 lb/2.2) × .9 = 58.5 mg total dose. She will receive 5.85 mg over the first minute, with the remaining 52.65 mg infused over the next 59 minutes. If each milliliter has 1 mg of medication, you will need to give 5.85 mL over the first minute.

15. Contraindications for beginning fibrinolytic therapy include which of the following? Select all that apply.

1. Systolic BP of 150
2. Worsening neurologic status
3. Major surgery in the last 14 days
4. Platelet count of less than 100,000 (100 x 10⁹/L)
5. Blood glucose of less than 50 mg/dL (2.8 mmol/L)
6. Currently on warfarin with an INR of 1.4
7. History of myocardial infarction 3 months ago

16. What are your responsibilities during the administration of Activase (tPA)?

Perform a neurologic check, assess VS, and inspect the infusion site for bleeding every 15 minutes for the first hour, every 30 minutes for the next 2 hours, and then hourly for 24 hours. Place an ECG monitor and pulse oximetry. Initiate bleeding precautions. If the drug is infusing peripherally, have her keep the extremity still and straight.

17. What signs and symptoms would alert you to the possible presence of an intracerebral hemorrhage during the tPA infusion?

Any new neurologic deterioration, new onset of a headache, sudden increase in BP, and vomiting

18. During the first 24 hours after Activase (tPA), the primary concern is controlling N.T.’s:

1. Glucose level
2. Blood pressure
3. Cardiac rhythm
4. Oxygen saturation

19. Why was N.T. placed on clopidogrel (Plavix) post-CVA?

Clopidogrel plus aspirin is currently recommended to prevent platelet aggregation, thereby reducing risk for a secondary CVA.

20. Because N.T. had a thrombolytic infusion, how many hours had to pass before starting any anticoagulant or antiplatelet drugs?

24 hours

21. Is there any benefit from continuing simvastatin?

HMG-CoA reductase inhibitors dramatically reduce the incidence of second CVAs. It is believed they stabilize the endothelial wall and prevent plaque ruptures.

22. While assessing N.T., you note the following findings. Which one is unrelated to the CVA?

1. Lethargy
2. Headache
3. Lumbar pain
4. Blurred vision

23. As you walk into the nurses’ station, the charge nurse is coordinating the swallowing evaluation, including a modified barium swallow study and referral for a speech-language pathologist (SLP). Give the rationale for these orders.

Because dysphagia was noted on the initial examination, a modified barium swallow study is done to show how fluids of various consistencies and food are taken into the mouth, chewed, propelled to the posterior pharynx, and swallowed. The SLP diagnoses dysphagia, recommends the safest position of the head for eating, and recommends the optimal food texture and liquid consistency to prevent aspiration.

24.If N.T.’s deficits are temporary, how long might it take before they completely reverse?

Maximum resolution of mild deficits usually takes 6 months to 1 year.

1.How would you explain ALS to T.H.?

ALS is a progressive neurodegenerative disease that attacks nerve cells in the brain and the spinal cord. It is a progressive, fatal disease that causes muscles to gradually weaken and atrophy until they finally cease to function.

2.Who gets ALS?

ALS affects adults; the incidence increases with age. Men are affected more frequently (60%). The majority (93%) are white. The cause of ALS is unknown; but about 5% to 10% of affected persons have a hereditary defect on chromosome 21.

3.How common is ALS?

ALS occurs at a rate of 2 per 100,000. Around 5600 people are diagnosed each year (15 cases per day in the United States).

4.What are the early manifestations of ALS?

Dysarthria and dysphagia; fatigue and malaise; asymmetrical muscle atrophy; outbursts of laughing or crying; hyperactive tendon reflexes; and twitching, cramping, and progressive muscle weakness, usually beginning with the legs and hands

5.What do patients with multiple sclerosis, myasthenia gravis, and ALS have in common?

1. Each is caused by a deficiency of essential neurotransmitters
2. Patients will experience a complete recovery after several months
3. The diseases place the patient at higher risk for respiratory complications
4. Manifestations include hyperactive deep tendon reflexes and muscle twitching

6.T.H. has many questions. He asks you, “How long can I expect to live?” How should you respond?

Be honest; tell him the truth. The average life expectancy is 3 to 5 years from the time of diagnosis. However, some people can live much longer and 10% to 20% survive for more than 25 years. However, some patients die in the first year after diagnosis.

7.T.H. asks, “Will I lose my mind?”

Probably not. ALS attacks the motor nerves only, and most patients do not experience impairment of the mind or thought processes. One of the most devastating facets of ALS is that the mind stays sharp, despite the progressive degeneration of the body.

8.T.H. then asks, “Are there any treatments for this?”

There are two medications, riluzole (Rilutek) and edaravone (Radicava), approved for treatment of ALS. Both appear to slow disease progression, but neither offer a cure.

9.T.H. thinks a moment, then says, “How is the doctor even sure this is what I have?” What is your response?

“ALS is a difficult disease to diagnose. No one test or procedure can definitively establish the diagnosis. Often the diagnosis is made by doing many other tests such as EMG, nerve conduction velocity tests, MRI, muscle and nerve biopsies, along with blood and urine tests, to rule out other diseases that mimic ALS.”

10. As part of this initial visit, you will begin to coordinate care with speech, occupational, respiratory, and physical therapists, as well as a dietitian and a psychologist. Describe the role that each of these professionals will play in T.H.’s treatment.

11. Which actions will support communication among T.H.’s care providers? Select all that apply.

1. Maintaining one central medical record
2. Designating the physician as the team leader
3. Having open communication among team members
4. Holding periodic team conferences to communicate goals
5. Inviting T.H. and his caregiver to take part in team conferences

12. You hold a family meeting to recruit adequate help for the caregiver—in this case, T.H.’s wife. Why is this important?

Research has shown that the probability of the patient being able to stay in the home as the disease progresses is linked directly to the availability of strong people to help provide care. A primary caregiver caring for the patient 24 hours per day will be unable to fulfill that role full-time for an extended period without experiencing caregiver strain. Therefore, you need to help them identify other sources of support, such as other family members, friends, and members of community groups.

13. What are some suggestions you can give T.H.’s wife to help her reduce caregiver strain?

The most valuable thing is for her to find opportunities for respite, setting aside time each day for rest or recreation away from T.H. This can be through use of other sources of support for longer outings outside the home or through taking moments of “alone time” in the home. She needs to make sure that she cares for herself and does not neglect things such as getting yearly health screenings and her needs for adequate rest, daily exercise, and a healthy diet. She may find participation in an online or local support group helpful, as well as use of relaxation techniques.

14. How would you best determine whether T.H.’s wife was experiencing caregiver strain?

1. Ask how well T.H. thinks his spouse is caring for him
2. Assess the caregiving situation and health of T.H. and his wife
3. Evaluate his wife for any new symptoms of anxiety and depression
4. Determine whether his wife feels overwhelmed by her responsibilities

15. T.H. asks you, “How will the end probably come for me?” What should you tell him?

The immediate cause of death in most patients with ALS is usually respiratory failure because the respiratory muscles are too weak to breathe. Some patients aspirate and develop pneumonia secondary to the inability to chew and swallow food or fluids.

16. T.H. wants to know whether he “has to be put on a breathing machine.” What factors will you take into consideration when deciding what to tell him?

Like all ALS patients, at some point T.H. will need respiratory support and will eventually face the difficult choice of deciding whether he will accept mechanical ventilation. The nurse must clearly communicate the inevitability of complete dependency on mechanical ventilation. Although mechanical ventilation will enable the patient to breathe and prolong survival, it does not alter progression of the disease. For this reason, many patients choose not to be placed on a mechanical ventilator. Encourage patients to discuss this with family and friends and to seek input from ALS support groups. Encourage patients to complete advance directives to indicate their desires for mechanical ventilation and other life-sustaining treatments. Reassess his plans periodically. Patients might change their minds based on their illness experience, changes in their subjective appreciation of their quality of life, or changes in their evaluation of the benefits and burdens of life-sustaining measures as they come to terms with the imminence of death.

17. Which legal document should T.H. formulate to describe his wishes about being placed on a “breathing machine”? Give your rationale.

1. Living will
2. Living trust
3. Standard will
4. Health care power of attorney

1.A seizure is not a disease in itself but a symptom of a disease. What is the term for chronically recurring seizures?

Epilepsy or seizure disorder (used interchangeably)

2.Does J.G. have epilepsy?

No, the seizure events result from the basal ganglion hematoma with infarct.

3.In addition to the brain injury, what are some other possible conditions that could be contributing to J.G.’s lowered seizure threshold?

Infection, postpartum eclampsia, hypertension, metabolic or nutritional disturbances, stress

4.What is the pathophysiology of a seizure?

A seizure is abnormal and an excessive electrical discharge of the neurons in the brain. Seizures result from the imbalance between excitation and inhibition within the CNS. This electrical activity can be limited to one specific area or can spread diffusely across brain tissue. Excessive excitation or excessive inhibition might occur in focal areas of the cerebral cortex (focal seizure) or over the entire cerebral cortex (generalized seizures).

5.J.G. had tonic-clonic, or grand mal, seizures. Describe this type of seizure.

They are characterized by loss of consciousness because of the rapid spread of electrical activity throughout the brain. In the tonic phase, the total body stiffens, respirations are temporarily interrupted, hands and jaw are clenched, pupils are dilated and nonreactive, and the person might be incontinent. This is followed by the clonic phase, which consists of violent, rhythmic muscle contractions, with hyperventilation. The face is contorted, the eyes roll, and there is excessive salivation with frothing from the mouth. Profuse sweating and tachycardia are common. The seizure usually lasts 2 to 4 minutes, followed by total relaxation and a period of unresponsiveness, known as the postictal state.

6.They ask how phenytoin (Dilantin) works in preventing seizures. How would you respond?

Dilantin works by affecting sodium channels in the motor cortex of the brain. It does not prevent abnormal brain activity from starting; instead, it prevents the abnormal activity from spreading to other parts of the brain. This action helps control seizures.

7.What factors are considered when determining which seizure medication a patient should take?

Type of seizures; the patient’s medical history; presence of other conditions; the person’s lifestyle and age; and, for a woman, the desire for pregnancy. For some patients, effective control may require therapy with more than one agent.

8.J.G. tells you she is having trouble remembering to take her medication. Why does this concern you?

Dilantin must be taken as prescribed to maintain constant therapeutic drug levels in the blood and lessen the risk for seizure activity.

9.What are some strategies you could suggest to J.G. and her husband to help her with remembering to take the phenytoin?

She could use a compartmentalized pillbox, then set an alarm for the prescribed time or place the pillbox or a sticky note in a location where she will see it and be reminded to take the medication. She could use an app that texts or chimes; she could arrange for someone to call and remind her to take her medication. She could make it part of her routine—for example, taking it with her breakfast each morning.

10. You check the chart and note that J.G.’s last phenytoin level was 12.7 mcg/mL (50.3 mcmol/L). What action do you expect based on this level?

1. Because this level is on the border of therapeutic, notify the neurologist.
2. This level is dangerously high, and an immediate reduction in dose is necessary.
3. J.G. is at immediate risk for a seizure so she should go to the emergency department.
4. Because this level is within normal limits, J.G. would continue therapy as prescribed.

11. J.G. asks, “Will my blood levels stay under control as long as I take my medicine?” How would you answer her question?

“Not necessarily. Drug levels might fluctuate, and the dose might need to be altered if you are under stress, become ill, need surgery, sustain trauma, or add other medications. That is why it is important we monitor your blood level at regular intervals and inform your neurologist about major changes in your life. You need to ask your neurologistbefore taking any other drugs, whether they are prescribed or over the counter because phenytoin interacts with many other drugs.”

12. J.G.’s husband asks if the phenytoin could harm his wife in any way. What general information would you review with them about phenytoin?

Explain that some drugs might cause blood, liver, or kidney problems. Instruct J.G. to observe and report easy bruising, petechiae, jaundice, dark urine, burning on urination, and abdominal pain. Emphasize that taking phenytoin and any nutrition supplement must be separated by 2 hours. Stress that it is very important for her to wear a medical alert bracelet or carry identification that specifies her seizure disorder. Inform them that the drug might exacerbate any fatigue and postpartum depression. Family planning should be considered; conceiving any more children should be carefully planned in consultation with J.G.’s neurologist. Because phenytoin is known for causing gingival hyperplasia, advise J.G. to perform frequent oral hygiene with gum massage and gentle flossing and to brush the teeth 3 or 4 times daily with a soft toothbrush. Stress the importance of regular dental visits. Stress the importance of getting blood work as ordered.

13. J.G. says that because she has not had a seizure since she was in the hospital, she questions how long she will have to continue taking the phenytoin. Which is your best response?

1. “Your seizures are cured only as long as you take the medication.”
2. “This medication might need to be continued for the rest of your life.”
3. “This medication can be stopped after you are seizure free for 6 months.”
4. “This medication will have to be taken only when you are experiencing stress.”

14. J.G.’s husband asks you what he should do if she has a seizure at home. What should you teach him?

Stay with her; ease her to the floor; loosen her clothing and remove eyeglasses. Protect her head from injury; try to keep the airway open with appropriate head position. Do not force anything into her mouth, and do not put your fingers in her mouth. Do not restrain her, but protect her arms and legs from injury. Try to place her on her side in case she vomits or has excessive oral secretions. Call for emergency help if she does not begin breathing after the seizure (start CPR), if a seizure lasts longer than 4 minutes, if she has one seizure right after another, or if she is injured during a seizure.

15. Her husband states that he is afraid for J.G. to take care of the baby. What would you say to him?

Acknowledge he has a valid concern. Tell him that it would be a good idea for someone to stay with her and the baby for several weeks. An OT referral could be beneficial; an OT could show them special ways of feeding, bathing, and looking after the baby that reduce the risk for injury should J.G. have a seizure. You could arrange for a maternal-child nurse practitioner to work with J.G.

16. What aspects of the home environment do you need to inspect and why?

Inspect the kitchen and bathroom because these are where most seizure-related home injuries occur. Because she has fallen, inspect the home for fall-related risks.

17. Describe safety measures you can teach J.G. that will minimize her risk of injury should she have a seizure.

When she is cooking, have her turn pot handles inward on the stove, and use the back rings or burners rather than the front. If possible, use the microwave instead of the stove. Special plastic microwaveable containers might be safer than other dishes. Heat mugs of water for hot drinks in the microwave instead of in a teapot. She should cook when another person is in the home. Taking a shower is safest. Place a well-fitted seat in the shower to prevent her from falling. Someone should be near her when she showers, and the door stay unlocked. Have them turn down the hot water temperature.

18. You would determine further teaching is needed regarding modifying their home environment to reduce J.G.’s risk of falling if J.G. or her husband states:

1. “The decorative rugs are all going to be put into storage.”
2. “We will put some nonskid strips in the shower in the master bath.”
3. “We will keep the stairway free of clutter and turn the light on as needed.”
4. “J.G. will need some new socks to wear so she is not going barefoot indoors.”

Chart View

Vital Signs

1.You note that the UAP has just entered these vital signs into J.B.’s record. What is your immediate concern and why?

That myasthenic crisis, an exacerbation of myasthenic symptoms, associated with his infection and need for increased medication, is occurring. Clinical manifestations of a myasthenic crisis are a sudden marked rise in BP, increased heart rate and respiratory rate with signs of distress. Immediate intervention is required to avert respiratory failure.

2.What action do you need to take based on this concern?

You need to assess J.B. for findings associated with myasthenic crisis and report suspicious findings immediately to the provider.

3.What other assessment findings would support this complication being present?

Wheezing or crackles with lung auscultation, diaphoresis, cyanosis, decreased oxygen saturation, and the absence of cough and swallowing reflexes

4.What is the physiologic difference between a cholinergic crisis and myasthenic crisis?

A myasthenic crisis is a sudden relapse of myasthenic symptoms in a patient with moderate to severe myasthenia or generalized myasthenia. A cholinergic crisis is an event precipitated by toxic effects of an anticholinesterase or a cholinesterase-inhibitor drug and the subsequent side effects; it is essentially a problem of overmedication.

5.What medical treatment do you anticipate for J.B.?

J.B. may need help to support adequate respiratory function, including mechanical ventilation. Plan to give edrophonium and IV gamma globulin; he may need immediate plasmapheresis. Hold cholinesterase-inhibiting drugs because they increase respiratory secretions and are usually ineffective for the first few days after a crisis.

6.What is your nursing priority at this time?

Maintaining a patent airway and adequate respiratory function

7.Based on this priority, what nursing interventions do you need to perform?

Place him in a minimum of semi-Fowler position; administer oxygen and suction as needed. Be prepared to assist with endotracheal intubation. Monitor VS frequently. Assess respiratory function by auscultation and observation of rate, rhythm, effort, and quality; evaluate respiratory values such as tidal volume and vital capacity. Assess swallowing to prevent aspiration; if J.B. has dysphagia, place him on NPO status.

8.Which actions do you need to implement to give edrophonium safely? Select all that apply.

1. Have IV atropine sulfate readily available.
2. Place J.B. on continuous cardiac monitoring.
3. Initiate precautions to prevent excessive bleeding.
4. Give an as-needed antiemetic drug before injection.
5. Monitor for any changes in his level of consciousness.

9.J.B.’s wife asks you, “What may have caused my husband to get worse, and why does he keep having these episodes?” What explanation should you give her?

The myasthenic crisis was likely caused by underdosage of anticholinergic drugs, the underlying infection, or the antibiotic ciprofloxacin, which has been known to cause profound muscular weakness in patients with MG.

10. J.B.’s wife tells you she does not have a lot of information about MG and she would like to know more about it. What should you tell her?

MG is a chronic disease that affects the transmission of signals from nerves to muscles. It is thought the immune system produces antibodies that block this transmission. The muscles cannot work very well; this is exhibited as muscle weakness. MG usually affects eye movement, facial expression, chewing, swallowing, speech, breathing, and head control. The muscle weakness increases during activity and improves after rest. Men in their 50s and 60s are commonly affected. It is not directly inherited or contagious.

11. They ask you to explain what to expect in terms of symptoms as his illness progresses. What should you tell them?

The rate of disease progression varies. The early symptoms, which he had, were ptosis and diplopia. The next muscles affected are the facial, masticator, speech, and neck muscles; thus, when he chews food, he becomes tired and must rest. He may have difficulty managing saliva because of difficulty swallowing. Most people develop generalized weakness, most often of the arms, legs, diaphragm, and neck. Weakness is greatest after use or toward the end of the day, when the patient is tired.

12. J.B.’s wife asks, “How do they know my husband has myasthenia gravis?” What should you tell her about how MG is diagnosed?

The diagnosis of MG is usually made based on history and physical examination. The patient usually reports that specific muscles become weak with activity and that a period of rest improves function. Anti–acetylcholine receptor (AChR) antibody (Ab) test results are positive in 90% of patients. EMG may show a decreased response to repeated stimulation of the hand muscles, indicating muscle fatigue. The Tensilon test in a patient with MG shows improved muscle contractility after IV injection of the anticholinesterase agent edrophonium chloride (Tensilon). In patients with a confirmed diagnosis of MG, a chest CT scan may be done to evaluate the thymus.

13. J.B.’s wife asks why he received plasmapheresis. Which statement best describes the purpose of this procedure? Plasmapheresis:

1. replaces affected blood with unaffected blood.
2. decreases the production of antireceptor antibodies.
3. reduces inflammation by infusing immunoglobulins.
4. removes circulating abnormal antibodies from the blood.

14. J.B. wants to know when he will be able to go home. How will you respond?

Most patients are managed at home after the crisis has resolved, treatments are completed, and the drug regimen is optimized. Explain that he will continue to need help once he is home. Discharge planning will involve working with and teaching his family members and those who will be involved in his care at home. Social services will be involved in identifying needs and arranging for use of community resources.

15. J.B.’s wife asks you what information they will need before he goes home. What do you need to teach J.B. about taking pyridostigmine?

Review the purpose, dose, and potential side effects. Have him take it at the same time each day, 30 minutes before meals, with a small amount of food to reduce GI upset. Avoid taking it with coffee or fruit juice. Remind him not to take OTC medications without the provider’s consent.

16. Outline other points you need to teach J.B. and his wife about managing myasthenia gravis.

17. You teach J.B. and his wife that the most effective means of preventing myasthenic and cholinergic crises is:

1. Doing all errands early in the day
2. Eating three large, well-balanced meals
3. Taking medications at the same time each day
4. Doing muscle-strengthening exercises twice a day

18. How will you know that your teaching has been effective?

J.B. and his wife are able to state: (1) names of each drug prescribed along with the dose, indication, possible adverse effects, and the importance of taking drugs on time; (2) four ways to achieve maximal muscle strength or endurance; (3) signs and symptoms of cholinergic and MG crises and how to intervene in a crisis situation; and (4) that J.B. will wear medical alert identification and carry written information regarding his prescribed drugs and dosages.

19. What community resources might J.B. and his wife find helpful?

They can join an MG support group and seek community resources, such as the Myasthenia Gravis Foundation of America. Discuss what he can do for intellectual stimulation when he cannot get out as much as he would like. Referrals that may help include a social worker, a physical therapist, and an occupational therapist.

1. What are common presenting symptoms of a brain tumor? Select all that apply.

1. Pallor
2. Ataxia
3. Diarrhea
4. Seizures
5. Vomiting with eating
6. Headaches, especially on awakening

Correct answers are: b, d, f

2. Explain the reason that a brain tumor can cause the signs and symptoms listed in Question #1.

Headaches, vomiting not related to meals or eating, ataxia, and seizures are potential signs and symptoms of a brain tumor. They generally are the result of increasing intracranial pressure (ICP) caused by the tumor.

3. Outline a plan of care for Z.O., describing at least 2 nursing interventions that would be appropriate for managing fluid status, providing preoperative teaching, facilitating family coping, and preparing Z.O. and his family for surgery.

Chart View

Postoperative Orders

Vital signs every 15 minutes × 4, and then every 15 to 30 minutes until stable
Contact surgeon for temperature less than 96.8° F (36° C) or over 101.3° F (38.5° C)
Maintain NPO until fully awake; may offer clear liquids as tolerated
Maintain Trendelenburg position
Reinforce bandage as needed
Neuro checks every 8 hours
Elbow restraints if needed

4. You check the postoperative orders written by the resident, which are listed in the chart. Which orders are appropriate, and which would you question? State your rationale.

Orders 3, 4, and 6 are causes for concern and would need to be verified. With an infratentorial craniotomy (done for cerebellar astrocytoma), the child is NPO at least 24 hours or longer if gag and swallow reflexes are depressed. Edema of the cranial nerves might depress these reflexes. The Trendelenburg position would increase ICP and should be avoided. The level of head of the bed as well as the position and degree of neck flexion should be determined by the surgeon. The patient is most often positioned flat and on either side per the physician’s orders. Neurologic checks after brain surgery should be at least every 1 to 2 hours. Vital signs should be taken frequently postoperatively. Thermoregulation issues reflected in low or high temperature can occur because of surgical intervention of the brain and anesthesia. Deviations should be reported immediately. The bandage should not be removed but rather reinforced with dry, sterile gauze until the surgeon removes it. Any excessive drainage or odor should be immediately reported. Elbow restraints may be needed in a younger child to protect the dressing and keep it intact.

5. You return to the room later in the shift to check on Z.O. Which assessment findings would cause concern? Select all that apply and explain your answers.

1. Facial edema
2. Heart rate 120 beats/min
3. Decreased responsiveness
4. Blood pressure 90/55 mm Hg
5. Increased clear drainage on dressing

6. Discuss some of the emotional issues Z.O.’s parents will experience during the immediate postoperative period.

The presence of a life-threatening illness evokes a family crisis. Some of the issues the parents might deal with include shock and disbelief, anger, guilt, deprivation and loss, anticipatory grieving, readjustment, and mourning.

7. Which actions are appropriate ways to assist the family during this time? Select all that apply.

1. Reassure them that everything will be fine.
2. Tell them you understand how they are feeling.
3. Ensure that they have as much privacy as possible.
4. Encourage them to talk about their feelings, if they can.
5. Remind them that they need to care of themselves to be able to care for their child.
6. Ask them if they would like to talk with the hospital chaplain and/or social worker.

Correct answers are: c, d, e, f

8. Which health care team members would you expect to be included in this interdisciplinary team? Select all that are appropriate and explain why you think they should be included.

1. Pharmacist
2. Oncologist
3. Neurologist
4. Hematologist
5. Neurosurgeon
6. General surgeon
7. Oncology social worker
8. Charge nurse and/or nurse caring for Z.O.
9. Oncology nurse practitioner/clinical nurse specialist

9. Outline a plan of care that addresses common risks secondary to chemotherapy, describing at least 2 nursing interventions that would be appropriate for managing risks for infection, bleeding, dehydration, altered growth and nutrition, altered skin integrity, and body image.

10. The unlicensed assistive personnel (UAP) is in the room caring for Z.O. Which safety observations would you need to address? Explain your answer.

1. UAP assists Z.O. out of bed to prevent a fall.
2. UAP encourages Z.O. to use a soft toothbrush for oral care.
3. UAP applies the disposable probe cover to the rectal thermometer.
4. UAP applies hand gel before and after assisting Z.O. to the restroom.

Chart View

Laboratory Test Results

11. Which laboratory results are you concerned about, and why?

The platelets are low and he is at risk for bleeding. The serum albumin is low and might reflect altered nutrition. The ANC is predictably low due to the chemotherapy, and he is at high risk for infection. Neutropenic precautions should be in place. The Hgb, Hct, and RBCs are normal but need to be monitored because he is at risk for anemia related to the chemotherapy.

12. Z.O. has a 5-year-old sister. She has been afraid of visiting at the hospital because her “brother might die.” Discuss a preschooler’s concept of death and strategies to help cope with the illness of a sibling.

13. Before the health care team decides on the new treatment goals and how to achieve them, what are some of the questions/issues you think should be addressed with the parents?

Is there a chance this relapse can be permanently cured? Is there a chance this relapse can be controlled for a while even if it will not result in a cure? Are there standard treatments with a relapse? Are there any clinical trials Z.O. would be eligible for?For each option, what are the likely medical, psychosocial, and social impacts for Z.O.? Can palliative care be involved even if there is hope for a cure?

14. After a long discussion with Z.O.’s parents, the health care team suggests hospice care. List at least 4 of the goals of hospice care for this patient and family.

15. Pain control, supplemental nutrition and hydration, and resuscitation are common ethical dilemmas nurses face when caring for terminally ill children. Complete the following chart, describing the common reasons for providing and withholding care for Pain Control, Supplemental Nutrition and Hydration, and Resuscitation.

1. What are some of the obstacles you need to consider, recognizing that Mrs. H. does not speak or understand English well?

If Mrs. H. is in the United States illegally, she might be reluctant to share personal information for fear of deportation. Mrs. H. might have a limited education and might not know what is important to share. There might be cultural practices or norms concerning health care practices.

2. You perform your primary assessment and question Mrs. H. with a translator. Which findings are abnormal and need to be reported? Select all that apply and state rationale.

1. High-pitched cry
2. Pupils equal and +3
3. Heart rate: 85 beats/min
4. Positive Babinski reflex
5. Refusal of PO intake per mother
6. Anterior fontanel palpable and tense
7. Temperature 36° C (96.8° F) rectally

3. Place an X where you would assess the Babinski reflex on an infant.

Chart View

Emergency Department Orders

CBC with differential
Blood culture
CMP
UA
Cerebrospinal fluid (CSF) for culture, glucose, protein, cell count (after lumbar puncture)
Ceftriaxone (Rocephin) 260 mg IV now (loading dose)
Ampicillin 400 mg IV now
Acetaminophen 50 mg suppository per rectum for irritability
D5W 0.45% NS to infuse at 15 mL/hr

4. Prioritize the order of your interventions, with 1 being your first action and 7 being your last action.

______ 1. Administer ceftriaxone (Rocephin) and Ampicillin
______ 2. Place IV
______ 3. Straight catheterization for urine specimen
______ 4. Place on contact isolation and droplet precautions
______ 5. Assist with lumbar puncture
______ 6. Administer acetaminophen
______ 7. Obtain blood culture, CMP

5. You have a difficult time placing the IV line, and the physician writes an order to give the ceftriaxone IM while you wait for the vascular access team to place the IV. Name the appropriate site for an IM injection for an infant.

vastus lateralis

6. Before administering the ceftriaxone (Rocephin) and Ampicillin, you verify the dose with another RN. The therapeutic range is for Rocephin 100 mg/kg loading dose and then 80 to 100 mg/kg daily. The therapeutic range for Ampicillin is 200 to 400 mg/kg/day in 4 divided doses with a maximum daily dosage of 12 g/day. J.H. weighs 3.5 kg. Is the loading dose ordered for Rocephin safe? Is it therapeutic? Is the ordered dose for Ampicillin, if given every 6 hours, safe and therapeutic? Show your work.

7. Interpret J.H.’s laboratory findings, and explain the rationale for abnormal results.

The urine is normal. Hgb and Hct are normal. The WBC count is elevated in response to an infection; sodium might be low, depending on his hydration status and any vomiting.

8. Interpret the CSF findings. Would you suspect bacterial or viral meningitis? Why?

The CSF findings are suggestive of bacterial meningitis. The specimen is usually clear and colorless. With a bacterial origin, you will find decreased glucose, increased protein, and primarily polymorphonuclear leukocytes. A viral origin usually causes a normal or slightly increased protein and normal glucose.

9. What are the most common bacterial pathogens in this age group?

In infants 1 to 3 months old, the most common causes are group B streptococci, Escherichia coli, Neisseria meningitidis, and Listeria monocytogenes. The introduction of the Haemophilus influenzae type b (Hib) and the Streptococcus pneumoniae (pneumococcal) vaccines have greatly reduced the incidence of meningitis from these pathogens.

10. Outline a plan of care for J.H., describing at least 2 nursing interventions that would be appropriate for managing pain and infection, maintaining hydration, assisting with increased intracranial pressure (ICP), and teaching to review with his parents.

11. According to the CDC immunization schedule, which immunizations will J.H. receive at 2 months? You can refer to the current immunization schedules posted at www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf

1. Hib
2. IPV
3. OPV
4. MMR
5. DTaP
6. Hep B
7. Varicella
8. Rotavirus
9. Pneumococcal conjugate (PCV13)

12. What is the effect of hospitalization on J.H.’s growth and development?

J.H. is in Erikson's stage of trust versus mistrust. His basic needs (diapering, feeding, comforting) must be met on a consistent basis. Having his parents participate in his care will help meet J.H.’s developmental needs, reinforce their parenting role, and promote their comfort level. It will also promote parent–infant bonding.

13. J.H. is being discharged after 3 weeks of IV antibiotic therapy. What educational topics will be important to discuss with J.H.’s parents when he is discharged?

14. You are providing developmental teaching to Mrs. H. with a translator. Which milestones would be appropriate to anticipate at 2 months? Select all that apply.

1. Coos and gurgles
2. Develops a social smile
3. Able to purposely reach for toys
4. Able to roll from stomach to back
5. Able to see an object 4 to 5 feet away (1.2 to 1.5 metres)

Correct answers are: a, b

1. Explain the pathophysiology of hydrocephalus and cerebrospinal fluid (CSF) imbalance.

CSF is produced and absorbed in the ventricles of the brain. Hydrocephalus is the result of too much CSF accumulation in the ventricles. This may result from impaired CSF absorption or CSF flow obstruction. Possible causes include congenital defects in the brain such as Chiari malformation, swelling from trauma (shaken baby syndrome) or infection, and tumors. As extra CSF collects in the ventricles, additional pressure builds in the cranial vault.

2. Explain how the placement of a VP shunt helps the patient.

The goal of treatment of hydrocephalus is to relieve ventricular pressure and treat the underlying cause. Placement of a VP shunt provides primary drainage and allows the CSF to drain into an extracranial compartment such as the peritoneal cavity, where it is absorbed.

3. A nursing student is assisting you with L.M.’s admission. Assessment of growth and development is an important part of patient assessment. Which of the nursing student’s statements is correct?

1. “We should not see any head lag.”
2. “L. should be able to focus on objects that are near.”
3. “We will assess her anterior fontanel because it should be closed.”
4. “I do not need to do a frontal occipital circumference measurement because her sutures have fused.”

Correct answer: b

4. Your assessment includes the following findings. Select the abnormal findings and state a possible rationale for each.

5. The doctors order a CT scan and lumbar puncture with a cell count, culture, Gram stain, glucose, and protein run on the CSF. What is the rationale for each procedure?

The CT scan will indicate whether there is an increase in CSF accumulation. The lumbar puncture and CSF laboratory results will show whether the patient has a shunt infection and differentiate a bacterial versus a viral cause.

6. True or False: The position of the EVD should be maintained at the level of the external auditory meatus (tragus). Explain your answer.

Chart View

Medication Administration Record (MAR)

Acetaminophen 15 mg/kg PO q4-6h prn
Morphine sulfate 0.05 mg/kg IV q4h prn
Enalapril (Vasotec) 5 mcg/kg PO q24h
Cefotaxime (Claforan) 150 mg/kg/day IV in divided doses q8h
Baclofen (Lioresal) 10 mg/kg/day PO q8h
Ondansetron (Zofran) 0.1 mg/kg IV now

7. Which medications are appropriate for L.M.’s diagnosis? Select all that apply and state the rationale for the ones you chose. Then, give a reason for those you feel are not appropriate.

Acetaminophen would be administered for fever or mild pain, but the route should be per rectum if NPO. Morphine is indicated for moderate pain. Cefotaxime is indicated for infection. Ondansetron is indicated for vomiting. Baclofen, a muscle relaxer, is not indicated in this situation. Enalapril, an angiotensin-converting enzyme (ACE) inhibitor, is used to treat hypertension, and is not indicated.

8. You are preparing to give the first dose of antibiotic that is ordered. Referring to L.M.’s medication administration record, calculate the amount of the antibiotic that you will administer per dose. Show your work.

9. L.M. is very fussy, and you decide to medicate her for pain. Calculate the amount of morphine L.M. will receive for pain per dose (do not round). Then calculate the amount you will draw up for the required dose, and mark the syringe appropriately (round to hundredths/two decimal places). The morphine is available in an injection solution of 2 mg/mL.

0.225 mg per dose (4.5 kg × 0.05 mg/kg = 0.225 mg)

Amount to draw up: 0.11 mL

2 mg:1 mL = 0.225 mg:x mL

2x = 0.225; x = 0.1125 or 0.11 mL

If the student writes “.225 mg” or “.11 mL,” the answer should be counted as wrong because leading zeroes are required. See www.jointcommission.org/facts_about_do_not_use_list/

10. Which task can be appropriately delegated to the UAP?

1. Changing the dressing on the surgical site
2. Obtaining a complete set of VS and charting them
3. Performing the every-2-hour neurologic check
4. Instructing the parents on changes in neurologic status

Correct answer: b

11. In which position should L.M. be placed immediately postoperatively unless ordered otherwise by the surgeon?

1. Flat, left side-lying
2. Flat, right side-lying
3. Supine, Trendelenburg
4. Supine, head of bed (HOB) 45 degrees

12. What points will you address while teaching the parents about the EVD system?

13. Based on the medications that L.M. is receiving, what is the most likely cause of the diarrhea? What is a possible concern you should consider, and what should your care plan include?

Antibiotics are often the cause of diarrhea in infants when used over time. Diarrhea has the potential to cause fluid and electrolyte imbalances. The care plan should include assessing mucous membranes, decreased weight, changes in VS, changes in behavior (level of consciousness), increased diarrhea output, altered skin integrity, and monitoring of electrolytes.

14. While you are giving your discharge instructions, L.M.’s mother states that she normally gives L.M. 1 mL of acetaminophen (Tylenol Elixir), 160 mg/5 mL, and asks whether this is the correct dose. L.M.’s current weight is 4.5 kg and the therapeutic range of acetaminophen dosage is 10 to 15 mg/kg PO q4-6h. Which statement is most accurate?

1. “Tylenol should not be given to a child her age.”
2. “This is a safe amount; you should continue to give that dose every 4 hours.”
3. “You should give 1.4 to 2.1 mL every 4 to 6 hours based on her current weight.”
4. “You can continue to give her that amount; you can give her a dose every 2 hours.”

15. When giving discharge instructions for this 2 month old, which guidelines/practices would help decrease the risk for a medication error occurring at home? Select all that apply. Then, give your rationale for why each answer is either appropriate or not.

1. L.M. may receive up to 6 doses of acetaminophen per day as needed.
2. Ask the pharmacist to give you an oral syringe to give the medication to L.M.
3. Give L.M. 1.4 to 2.1 mL every 4 to 6 hours as needed, which is based on her weight at this time
4. You should give L.M. 2 mL every 4 to 6 hours as needed, which is based on her weight at this time.
5. Give parents detailed medication instructions, such as demonstration and return demonstrations and picture-based-dosing instructions.

1. What is the rationale for doing a cesarean delivery for babies with myelomeningocele?

The sac needs to be protected from trauma. Any opening in the sac increases the risk for infection and trauma to the central nervous system.

2. Using lay terms, what would you tell the father about the pathophysiology of myelomeningocele? What is the difference between myelomeningocele and meningocele?

The nerves of the spinal cord send messages to other parts of the body to help with sensations and movement. When your baby was growing, the tube of the spinal cord did not close all the way. The myelomeningocele sac contains spinal fluid and some of the nerves and meninges, which are layers of tissue that cover the brain and spinal cord. In babies with meningocele, the sac contains meninges and spinal fluid but no nerves from the spinal cord.

3. After your discussion with the family, which of the father’s statements would indicate a need for more teaching?

1. “My baby will need to lie on her stomach in her incubator.”
2. “I need to wash my hands carefully to prevent spread of germs.”
3. “My baby will probably not require surgery until she is a year old.”
4. “My baby’s malformation can also be referred to as spina bifida cystica.”

Correct answer: c

4. The father asks questions about the infant’s condition but does not look at his newborn. Which statements are correct? Select all that apply.

1. People grieve for the loss of a “normal newborn” differently.
2. Most new fathers are not interested in looking at their newborns.
3. It is apparent that he does not care about his newborn’s condition.
4. This is an abnormal reaction for a parent of a child born with a very visible physical defect.
5. Even though the myelomeningocele was diagnosed in utero, seeing the congenital anomaly or physical defect on his infant is very difficult.

Correct answers are: a and e

Chart View

Admission Data

5. Which assessment and monitoring data are abnormal for a 1-hour-old infant? Select all that apply.

1. Acrocyanosis
2. Bilateral clubfeet
3. Breath sounds clear
4. Fontanelles soft and flat
5. Pupils 2 cm, brisk reaction
6. Sleepy, squirms and fusses during pupil check
7. No reaction when pulse oximeter is placed on right foot
8. Pulses 2+ and capillary refill time less than 2 to 3 seconds

6. You are carefully assessing the sutures and fontanelles. True or False: The posterior fontanel is joined by the temporal and parietal bones.

7. Explain the rationale for each order in the table.

8. You add 10 mL of sterile water to the 1-g vial for a concentration of 100 mg/1 mL. Calculate how many milliliters you will draw up for this dose. Shade in the dose on the syringe.

1.4 mL (100 mg/1 mL × 140 mg/x mL = 1.4 mL)

9. Which of the issues should you address first? Give rationale.

The oxygen saturation is the priority. Airway and breathing have been affected and take priority over everything else. Temperature of 35° C (95° F) might be a contributing factor to be addressed after the patient’s condition has been stabilized. Then address the suture’s integrity.

10. How can you help the parents become comfortable with holding their baby?

Discuss the importance of keeping the infant on her side or prone to protect the suture, and reassure them that holding her is safe. Show them how to safely hold the baby, holding her upright against the body to prevent pressure to operative site. Offer to transfer her from the bed to them and stay with them as they hold her. Discuss the importance of bonding and touch in newborns and the effect on the baby’s physical, mental, and emotional health.

11. When you take the bottle into the room, you notice a growth chart next to the bed tracking the FOC measurement at least once per shift. Baby Girl R.’s FOC has increased to 36 cm. Using the appropriate WHO (World Health Organization) growth chart (www.who.int/childgrowth/standards/second_set/cht_hcfa_girls_p_0_13.pdf?ua=1) is the following statement True or False? The FOC is close to the 95th percentile and can be monitored less frequently because this is a normal finding. (Explain your answer.)

12. Which topics would be important to include in discharge teaching for Baby Girl R.? Select all that apply.

1. Positioning
2. Skin care and wound care
3. Specialized feeding technique
4. Maintenance of the Foley catheter
5. Comfort measures and pain control
6. Importance of multidisciplinary follow-up
7. Signs and symptoms of when to call the physician
8. Range-of-motion (ROM) exercises as appropriate per PT
9. Appropriate stimulation such as sitting in an infant seat or swing

All are correct except d and i. Sitting in an infant seat or swing could cause increased pressure on the surgical site. Clean intermittent catheterization is recommended as needed rather than a Foley catheter to decrease the risk of a catheter associated urinary tract infection (CAUTI).

1.What is your immediate concern for A.A.?

Total airway collapse or obstruction resulting in hypoxia leading to brain damage

2.List 5 things you would do in order of priority.

3.Given A.A.’s history, state 3 possible causes for his tonic-clonic seizure.

Withdrawal from alcohol and/or illicit drugs, meningitis, head injury, stroke, metabolic and toxic encephalopathies (such as the onset of nonketotic hyperglycemia), undiagnosed seizure disorder, and an undiagnosed progressive neurologic or neurodegenerative disorder

Chart View

Medication Administration Record

Thiamine (vitamin B₁) 100 mg IM now
50% glucose, 1 50-mL IV bolus now
Lorazepam (Ativan) 4 mg IV now over 2 to 5 minutes

4.Indicate the expected outcome for A.A. associated with each medication.

5.In what order would you give A.A.’s medications? Give your reason.

_____ Thiamine (Vitamin B₁)
_____ Glucose
_____ Lorazepam (Ativan)

6.List your primary concern when giving lorazepam intravenously.

Respiratory depression or hypotension

7.(S) The lorazepam is supplied in a single-use vial. How many milliliters will A.A. receive? Shade in the dose on the syringe.

Correct answer: 1 mL

8.What assessments do you need to make during his ongoing seizure activity?

Monitor the actual seizure, including body parts involved and any symptom progression, state of consciousness, respiratory pattern, salivation, pupil size and eye movement, any incontinence of urine and stool, and vomiting

9.What is the significance of this time lapse?

If seizures persist beyond 30 minutes, a vicious cycle of maladaptive physiologic responses occurs. The seizures cause a marked increase in cerebral metabolic activity and demands. These demands might outpace the delivery of O₂ and nutrients from the cerebral blood flow; further seizures then lead to extreme cerebral hypoxia that can result in severe, irreversible neurologic deficits and even death.

10. Define status epilepticus.

Either a series of consecutive seizures without the person regaining consciousness in between or a single seizure that does not respond to conventional therapy or lasts more than 30 minutes

11. The provider decides to administer propofol (Diprivan) and intubate A.A. to support his airway. What is propofol? Why is it being given to A.A.?

Propofol is a parenteral general anesthetic used for inducing and maintaining general anesthesia and for sedation for mechanical ventilation. Giving propofol to A.A. will allow for easier intubation, assist with optimal ventilation once he is intubated, and might assist in the cessation of seizure activity.

12. The provider also orders a phenytoin 15 mg/kg IV loading dose at a rate of 50 mg/min. What is the reason for giving A.A. phenytoin?

Phenytoin is an anticonvulsant that might inhibit the spread of abnormal electrical impulses in the motor cortex and brain stem. It is often given after a benzodiazepine, such as lorazepam, because it has a longer duration of effect.

13. (S) A.A. weighs 143 pounds. How much phenytoin will you administer?

14. (S) As you prepare to administer the phenytoin, you see that A.A. has D5W infusing at 75 mL/hr. Why does this concern you, and what are your options?

Phenytoin must be given with 0.9% normal saline because it will precipitate in the presence of D₅W. You have 2 options: (1) Keep the current IV infusion of D₅W. Start a second line and infuse the phenytoin through that site or (2) change the current IV solution to 0.9% normal saline and then administer the phenytoin. Flush the line and resume the D₅W after the phenytoin is complete.

15. You accompany A.A. as the rapid response team transfers him to the ICU. During the transport, his seizure activity ceases. Using SBAR, what information will you provide to the ICU nurse?

You would first identify yourself, then explain that A.A. has experienced prolonged seizure activity. State that he was admitted 18 hours ago with peptic ulcer disease secondary to suspected alcohol use, then give current VS; details of his respiratory examination findings; and what happened during the actual seizure, including total time, body parts involved, neurologic status including level of consciousness, and the occurrence of any incontinence of urine and stool or vomiting. Describe the interventions A.A. has undergone, including the emergency medications administered, and review his current status, including all of A.A.’s current care needs.

16. What are the main complications of status epilepticus that the nurse will monitor for?

Hypotension, hypertension, hyperthermia, hypoglycemia, hypoxemia, metabolic acidosis, cerebral edema, electrolyte disturbances, dysrhythmias, rhabdomyolysis, pulmonary edema, renal failure, and injuries such as fractures and oral trauma.

17. Describe the assessment A.A. needs over the next few hours.

During the postictal phase of the seizure, assessment should include VS, level of consciousness, motor response to stimuli, and speech every 15 minutes for the first hour, then every 30 minutes for 2 hours. As effects of propofol wear off, assess respiratory status and prepare for extubation and initiate alternative O₂ therapy. Check his tongue, lips, and mouth for lacerations and assess skin for bruises, lacerations, or shearing. Monitor urine output and for myoglobinuria and a red or cola color, which might signal rhabdomyolysis from muscle damage. Monitor for weakness or paralysis, aphasia, or visual disturbances. Check blood glucose and obtain serum laboratory tests as prescribed.

18. Identify nursing interventions that are appropriate for A.A. since the seizure activity has subsided.

Reassure and gently reorient A.A. Provide a quiet, calm environment because sounds and stimuli can be confusing to the awakening patient. Keep talk simple and to a minimum. Speak slowly and with pauses between sentences. Repeating might be necessary. Use room light that is behind, not above, the patient to prevent additional seizures and for patient comfort. Maintain seizure precautions and administer medications as prescribed.

Chart View

Physician’s Orders

Insert indwelling urinary catheter
ECG monitoring
Immobilize the cervical spine
Oxygen at 4 L per nasal cannula
Neurologic assessment every hour
Apply warming blankets as needed

1.Describe a plan for implementing these orders.

Using the ABCD (Airway, Breathing, Circulation, Disability) system, the first action is to ensure that the cervical spine is immobilized, then initiate oxygen at 4 L per nasal cannula. Place the patient on an ECG monitor and perform the neurologic assessment. Apply warming blankets if his temperature is low. Finally, insert the indwelling catheter.

2.What are the nursing priorities at this time?

Ensuring an adequate airway, maintaining ventilation, supporting adequate circulation, and preventing further injury

3.Which assessment would you complete first?

1. Auscultating breath sounds
2. Testing the peripheral reflexes
3. Determining pupil response to light
4. Assessing ability to move the extremities

4.What other interventions would likely be done by the ED nurse?

Having suction and ability to provide mechanical ventilation available, inserting a nasogastric tube for decompression, providing psychosocial support and education to T.W. and his family, administering IV fluid replacement and high-dose steroids, initiating skin care early, assisting in preparation for application of immobilization

5.Awareness of the prehospital management of a SCI is critical to T.W.’s ultimate neurologic outcome. What actions will the nurse take to ensure this goal is met?

Take a thorough history of the accident and all subsequent events until the arrival of emergency medical technicians or other medical first responders. Make certain each first responder’s transport information is incorporated into the patient’s chart.

6.T.W. anxiously asks, “With this broken back, am I going to be paralyzed for life or can it be reversed?” How would you respond?

Tell him it is very important that he stays still to minimize any further injuries. The health care team is doing the best they can to help him, but the full extent of his injuries will not be known for about 3 days.

7.How would you explain spinal shock to T.W.’s family and why T.W. needs mechanical ventilation?

With most SCIs, there is an initial period of flaccid paralysis with a complete loss of motor, sensory, and reflex functions below the level of injury. This areflexic period, as spinal shock might be described, is temporary, occurs shortly after the injury and lasts days to weeks. The loss of systemic sympathetic vasomotor tone might result in vasodilation, increased venous capacity, and hypotension. During this time, the patient might need respiratory support. The return of sacral reflexes indicates resolution.

8.Indicate the reason T.W. is receiving each medication.

Pantoprazole reduces acid to help prevent stress ulcer. Enoxaparin is part of DVT prophylaxis. Propofol is used to maintain sedation and facilitate ventilation.

9. T.W. weighs 158 pounds. The pharmacy-supplied infusion bottle reads “propofol 500 mg/50 mL.” At how many milliliters per hour would you set the infusion pump? (Round to the nearest hundredth.)

10. After the CVC is inserted, T.W. has a STAT portable chest x-ray examination. Why?

The CXR is taken to determine whether the catheter accidentally created a pneumothorax or hemothorax during insertion and to confirm that the catheter tip is in the superior vena cava. Nothing should infuse through the catheter until it has been confirmed that the catheter was properly placed.

11. What complication do you suspect T.W. is experiencing and why?

Because of his symptoms and level of spinal injury, you suspect he may have autonomic dysreflexia (AD). AD is a syndrome of a sudden and dangerous increase in BP that can occur any time after spinal shock resolves due to unopposed sympathetic nervous system discharge. It occurs in patients injured above the splanchnic outflow, which is at level T6 or above. A noxious stimulus below the level of injury triggers a massive, uncompensated cardiovascular response of the sympathetic nervous system, causing a massive release of catecholamines and producing vasoconstriction below the lesion.

12. What further assessment data do you need to collect?

Measure T.W.’s vital signs, evaluating for hypertension and bradycardia; assess for vision changes and nasal congestion; and inspect for pallor or goose bumps below the level of injury. Assess for potential causes, including urinary concerns, such as bladder distention, obstruction, spasms, catheterization; bowel constipation, fecal impaction, or rectal stimulation; and alterations in skin integrity, including pressure from restrictive clothing, pressure injuries, and exposure to cold or hot.

13. What interventions do you need to perform for T.W.?

14. What could happen if autonomic dysreflexia (AD) is left untreated?

Seizure, retinal hemorrhage, cerebrovascular accident, cerebral hemorrhage, acute pulmonary edema, loss of consciousness, and even death

15. After your prompt intervention, T.W.’s AD resolves and you need to document what happened. Write an example of a documentation entry describing this event.

Answers will vary but should include the time, a description of T.W.’s complaints, the assessment findings, the actions taken by the nurse, including correcting the probable cause of the AD, and the patient’s response to any therapies.

16. What members of the interprofessional team would likely be involved in his care?

Physicians, rehabilitation nurses, physical, occupational and speech therapists, case managers, psychologists, dietitians, and pastoral care

17. What are realistic functional goals for T.W.?

He will have normal function in the head, neck, shoulders, and upper extremities with fair chest control. This should allow him to be totally independent with all activities. He may have limited walking with extensive bracing or be able to stand by using bilateral knee-ankle-foot orthoses along with a walker or crutches.

18. Part of rehabilitation care includes teaching T.W. how to manage his continuous urinary drainage system. What would this teaching include?

19. What outcome parameters would you use to determine whether efforts to promote urinary excretion have been effective?

T.W. will have an optimal pattern of urinary elimination as evidenced by urinary output without incontinence, emptying the bladder with residual volumes of less than 50 mL, or an absence of bladder distention. T.W. should be free of UTIs, have a balanced intake and output with a urine output of at least 30 mL/hr, and no signs of skin breakdown.

20. T.W. is experiencing some spasticity of the lower extremities. What should be included in the plan of care to prevent developing contractures of the lower extremities?

Contractures can be prevented by performing regular, sustained range-of-motion movements 1- 2 times/day with muscle stretching and proper positioning. If contractures develop, range-of-motion exercises are the recommended treatment in most cases.

21. T.W. has special dietary needs, and the registered dietitian is part of developing an optimal diet for T.W. Describe the components of this diet.

Because of severe catabolism, a high-protein, high-calorie diet is necessary for energy and tissue repair. Daily energy needs are approximately 28 kcal/kg for paraplegics. However, too much protein can stress his kidneys. The dietitian will adjust his diet to ensure adequate amounts of protein, carbohydrates, calcium, thiamine, niacin, vitamins B6 and D, magnesium, and zinc.

22. T.W. will be taught bowel-training techniques. What will this teaching include?

23. T.W. is concerned whether he will ever be able to have sex again. What would you tell him, and what are some possible referrals?

Sexual function is likely to be affected by his SCI. He may notice changes in his ability to achieve an erection and ejacul*te. Many techniques are available to increase erection, such as drugs, vacuum pumps, erection rings, and penile prostheses. Doctors and urologists who specialize in SCI can offer options for sexual functioning and fertility.

24. While assisting T.W. with his morning hygienic care, he states, “Why would anyone want to live like this? No woman will ever want me. I just wish you would have let me die.” How would you initially respond?

1. “You wish you would have died?”
2. “Tell me why you are talking like this.”
3. “Let’s finish your bath and then we can talk.”
4. “I know this is hard now, but things will work out.”

1.What steps will you take to assess J.R.?

Using the ABCD (Airway, Breathing, Circulation, Disability) system, the first action is to ensure that the cervical spine is immobilized, his airway is patent, begin as-needed oxygen therapy, and start ECG monitoring. Then perform the neurologic examination and determine the extent of disability. Evaluate the scalp laceration.

2.List at least 6 components of a neurologic examination.

Glasgow Coma Scale, including eye opening, best motor response, best verbal response; level of consciousness (LOC); pupil size, shape, and reaction to light; extraocular eye movements; sensation (superficial—light touch, pain, temperature; deep—vibration, deep pain, proprioception); behavior status (e.g., combative, cooperative, calm); motor tone and strength (hand grips, pronator drift, leg movement, motor strength of extremities); cranial nerve assessment; VS (Cushing’s response with increased systolic BP, widened pulse pressure, bradycardia, and altered respiratory patterns); cerebellar functioning (rapid alternating movements, heel to shin, Romberg sign, nystagmus); other reflexes (deep tendon, Babinski reflex)

3.What types of injuries may J.R. have sustained?

J.R. may have a skull fracture, cervical spine injury, brain contusion, concussion, epidural or subdural hematoma, or intracranial hemorrhage

4.Differentiate between primary and secondary head injury.

A primary head injury is the initial tissue damage resulting from the traumatic impact. It can include the scalp, skull, or brain tissue itself. A secondary head injury complicates the primary injury and causes further damage, resulting in a worse outcome or increased risk for death. Secondary injuries include intracranial hemorrhage, cerebral edema, increased ICP, hypoxic (ischemic) brain damage, and infection.

5.What complication common to each of these diagnoses concerns you most?

Increased ICP because it could lead to brain herniation and death.

6.Why is this complication clinically important?

A sustained increased ICP greater than 15 mm Hg can result in decreased arterial blood flow to brain tissue and decreased O₂ delivery to brain tissues; if sustained, elevated ICP might lead to brain anoxia, atrophy, herniation, or death.

7.Name at least 6 findings that would indicate this complication is occurring.

Altered or decreased LOC, worsening headache; pupillary dysfunction, blurred vision; weakness or sensorimotor changes; nausea and vomiting; restlessness; drowsiness; changes in speech or loss of judgment; change in personality; alteration in VS such as a widened pulse pressure, bradycardia; change in respiratory pattern; increased BP; and impaired reflexes such as corneal or swallow and abnormal posturing

8.Which one is the most sensitive indicator of neurologic change?

Change in LOC

9.What are the next actions you will take?

Assess ABCs, perform a neurologic assessment, and immediately notify the provider of his change in LOC

10. What is this response called and what does it signify?

Decerebrate posturing, characterized by abnormally extending his extremities to painful stimuli. It signifies increased ICP and a decline in neurologic functioning.

11. Calculate J.R.’s GCS score. Describe the clinical implications of this score.

GCS = 5; no eye opening = 1, flexion to pain = 3, no verbal response = 1. This is a medical emergency, and you need to notify the provider immediately.

12. What is the most likely cause of the change in J.R.’s neurologic status?

Increased ICP from bleeding

13. What are your immediate nursing priorities?

Ensure an adequate airway, maintain ventilation, and prevent further injury through reducing ICP

14. What immediate actions will you take?

Make certain the airway is open and clear. Apply O₂ therapy. Elevate the head of the bed 30 to 35 degrees and keep his head in a neutral position. Institute ECG and automatic BP monitoring; obtain J.R.’s vital signs. Insure large-bore IV access.

15. His vital signs are now 160/72, 64, 10, 98.7° F (37.1° C), and Spo₂ 94%. What is your concern and why?

Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing’s triad. ICP has increased, and brain herniation mayoccur unless immediate action is taken to lower ICP.

Chart View

Physician’s Orders

Insert indwelling urinary catheter
Insert nasogastric tube to continuous low wall suction
Intubate: Vent settings assist-control 16, V_T 900 mL, Fio₂ 0.5, PEEP (positive end-expiratory pressure) 3 cm
IV fluid 0.9% normal saline at 100 mL/hr
160 grams Mannitol IV STAT over 30 minutes
Phenytoin 1360 mg IV STAT over 30 minutes, then 100 mg IV every 8 hours
STAT CT scan
STAT labs: CBC, CMP, UA, type and cross, PT/INR and PTT, ABGs, toxicology screen

16. Outline a plan for implementing these orders.

Have designated personnel perform endotracheal intubation and initiate mechanical ventilation. Have assistive personnel arrange CT scan while you start the IV fluids and begin the mannitol and phenytoin infusions. Draw the STAT trauma labs. Finally, insert the Foley catheter and nasogastric tubes. Continue to frequently monitor the VS and neurologic status while performing interventions.

17. What is mannitol, and why is it being given to J.R.?

Mannitol is an osmotic diuretic that draws fluid from the interstitial to the intravascular space, where the kidneys eliminate it. It is being administered in J.R.’s case to reduce cerebral edema and prevent herniation.

18. What is the expected outcome associated with administering phenytoin to J.R.?

Early seizure prophylaxis with an anticonvulsant, such as phenytoin, is used for patients at high risk for experiencing a seizure. Seizures increase metabolism, which increases cerebral blood flow and ICP.

19. How should you respond?

Explain you are very sorry they missed him, but he immediately went to surgery. Tell them that as soon as he is out of surgery and in the ICU and stable, a nurse will let them know when they can visit him. Show them where they can wait until surgery is over so they can talk with the provider. Call the operating room and notify staff that the family has arrived and where they will be waiting to talk to the provider after surgery. Offer to make them comfortable and ask whether there is anything they need. Ask if they would like the chaplain to visit them while they wait.

20. What assessment indicators will be closely monitored in J.R.?

Complete neurologic assessment, including pupil size, equality, and response to light; and LOC, response to commands, and reflexes; ICP monitoring; presence of any cerebrospinal fluid drainage; capnography; hemodynamic status, including arterial BP and cerebral perfusion pressure; intake and output with hourly urine output monitoring; laboratory reports

21. An appropriate nursing intervention for J.R. to promote cerebral tissue perfusion is:

1. Avoiding passive range-of-motion exercises
2. Repositioning him every 4 to 6 hours, using logrolling
3. Limiting endotracheal suctioning to no longer than 15 seconds
4. Clustering nursing activities so he has periods of uninterrupted rest

22. The best way to position J.R. is to:

1. Elevate the head of the bed to 30 degrees
2. Keep him flat with his hips slightly flexed
3. Place him on the right side with his head flexed
4. Turn his head from side-to-side to decrease aspiration risk

23. Name 4 independent nursing interventions that would be used to control environmental stimuli during the first 48 postoperative hours.

Provide a quiet and soothing environment. Control stimuli (noise, temperature, light, odors). A quiet environment reduces meningeal irritation and promotes pain control; both reduce ICP. Speak softly, explain procedures before touching to avoid startling, and avoid jarring the bed. Limit painful procedures; avoid tension on tubes (e.g., urinary catheter); and consider limiting pain-stimulation testing. Avoid unnecessary touching.

24. What measures will be used to prevent J.R. from developing hyperthermia? Why are these important?

Frequently monitor temperature. Give prescribed antipyretics, regulate the temperature of the environment, limit the use of blankets, keep his trunk warm to prevent shivering, and administer tepid sponge baths or use a hypothermia blanket or convection cooling units to reduce fever. Hyperthermia aggravates hypoxia and can increase ICP.

25. What outcome criteria would determine whether the independent nursing measures for J.R. were effective?

He is free of symptoms of ICP as shown by a stable or improving Glasgow Coma Scale score; stable or improving sensorimotor functioning; BP within his normal range; heart rate 60 to 100 bpm; normal vision; PERRLA; respiratory rate 12 to 20 breaths/min with normal depth and pattern; normal gag, corneal, and swallowing reflexes; absence of headache, dizziness, nausea, and seizure activity; no visual or speech disturbances

1.Describe C.J.’s neurologic presentation that equates with a GCS score of 3.

GCS score of 3: She is completely unresponsive with no verbal or motor response to painful stimuli, she has complete muscular flaccidity, and her eyes do not open.

2.The provider immediately suspects a subarachnoid hemorrhage (SAH). Why?

A hallmark sign of a SAH is a person describing “the worst headache” of his or her life followed by a rapid decrease in level of consciousness.

3.What is a SAH?

A SAH results in bleeding into the subarachnoid space of the brain, between the arachnoid membrane and the pia mater.

4.What are common causes of an SAH?

Hypertensive hemorrhage, ruptured cerebral aneurysm (85%), ruptured arteriovenous (AV) malformation, and head injury

5.What are C.J.’s risk factors for a SAH?

Hypertension, nonadherence to HTN therapy, smoking, alcohol, stimulant use

6.Describe a patient with a grade V SAH.

With grade V SAH the patient is in a deep coma, with the highest level of function being decerebrate rigidity and moribund appearance. The prognosis is extremely poor.

7.What common complications of SAH would you anticipate?

Vasospasm, rebleeding, increased intracranial pressure (ICP), hydrocephalus, and seizures

8.What is the likely goal of treatment for C.J.?

Decrease the risk for rebleeding and prevent further neurologic deterioration

9.Treatment of SAH can include surgery, embolization, medications, and watchful waiting. What factors are considered in determining treatment?

Treatment options depend on the age of the patient, size of the aneurysm, location, neurologic condition (grade), co-morbidities, and previous medical problems.

Chart View

Physician’s Orders

Nimodipine 60 mg every 4 hours per NG tube for systolic BP >140
0.9% normal saline at 100 mL/hr
Labetalol 10 mg IV over 2 minutes q1h for systolic BP >140
Acetaminophen 650 mg q6h for temperature greater than 101.0° F (38.3° C)
Insulin aspart (NovoLog) subcut per sliding scale every 6 hours

10. Identify the expected outcome associated with each treatment C.J. is receiving.

Nimodipine is a calcium channel blocker that reduces vasospasms after SAH. Labetalol is an adrenergic receptor blocker that reduces blood pressure, thereby decreasing the risk for rebleeding associated with hypertension. SAH may result in diabetes insipidus, which can cause hypovolemia. Circulatory volume is maintained with the use of isotonic saline. Fever occurs in up to 72% of aneurysmal SAH patients. It is necessary to keep the patient’s core body temperature at 99.0° F (37.2° C) or less. Hyperglycemia is common in patients with SAH and associated with increased risk for vasospasm. Rapid-acting insulin is given to a target glucose range of 80 to 140 mg/dL (4.4 to 7.8 mmol/L).

11. Name 4 independent nursing interventions that would be used to control environmental stimuli during the next 24 hours.

Provide a quiet and soothing environment. Control stimuli (noise, temperature, light, odors). A quiet environment reduces meningeal irritation and promotes pain control; bothreduce ICP. Speak softly, explain procedures before touching to avoid startling, and avoid jarring the bed. Limit painful procedures, avoid tension on tubes (e.g., urinary catheter), and consider limiting pain-stimulation testing. Avoid unnecessary touching.

12. How would you position C.J.?

Elevate the head of the bed 30 to 45 degrees. The head and neck need to remain in a neutral position.

13. What assessment indicators will be closely monitored in C.J.?

Complete neurologic assessment, including pupil size, equality, and response to light; and LOC, and reflexes; ICP monitoring; capnography; hemodynamic status, including arterial BP and cerebral perfusion pressure; intake and output with hourly urine output monitoring; laboratory reports

14. Describe how you would support C.J.’s family during this time.

Assess what they know so far about C.J.’s condition. Ask what they would like to know, has anything like this ever happened to their family before, has anyone ever been in an ICU before? Assess the family’s health care literacy and culturally specific education needs. Orient them to the environment and the ICU routines. Explain the equipment, monitors, and alarms to the degree they desire. Keep them updated on her condition and any changes in condition and the plan of care. Help family members use the information they receive to make health care decisions about the patient. Arrange pastoral care if desired. If possible, offer open, flexible visitation. Ensure that they have access to amenities, such as beverages, food, tissues, blankets, and restroom facilities.

15. What is brain death?

In the United States, brain death is defined as the irreversible loss of all brain functions, including the brain stem. Brain death is a clinical diagnosis. It can be made in patients whose hearts beat and are maintained on mechanical ventilation in the ICU.

16. What are the general criteria for declaring a patient clinically brain dead?

Absent brain stem reflexes (e.g., a complete absence of spontaneous movement and breathing, pupil response absent, no corneal or gag reflex, no oculovestibular reflex to ice water calorics); electroencephalogram shows no brain activity or response; and coma irreversibility continued over a specific time frame. Brain stem auditory evoked responses and cerebral blood flow studies, including transcranial Doppler, angiography, and brain scan with a cerebral perfusion agent, may be used to help confirm brain death.

17. It is determined that C.J.’s condition meets the criteria, and she is declared legally brain dead. She had previously indicated her willingness to be an organ donor, and her husband agrees to honor her wishes. C.J.’s husband asks you to explain the donation process. How will you explain it to him?

After a potential organ donor has been officially declared brain dead, management shifts to providing care that preserves and promotes organ function and viability. The local organ procurement organization is contacted. Once involved, they are responsible for determining the suitability for organ and tissue donation and coordinating organ recovery, obtaining family consent, and managing the donor’s care until organ removal is complete. After permission has been given, the hospital enters the donor’s vital statistics, such as height, weight, and blood type, into a national organ donation database. This information is matched with patients in the database. Once a match has been made, the organs are harvested for transport to the recipient. This is usually done very soon after the donor’s death, although donation of some tissues such as skin can be delayed. Organs are recovered by surgeons in the operating room of the donor’s hospital then taken to the respective transplant centers for transplantation. After donation is complete, the body is transferred to the funeral home. After the organ transplants have been completed, a letter is often sent to the donor’s family that outlines information about the outcome of the donations. Care is taken to preserve the identity and location of the recipient(s), but general information is given about how they are doing after receiving their transplant.

18. While you are waiting for the transplant team to arrive, you are working to maintain C.J.’s hemodynamic stability. Which parameter would indicate your efforts are successful? Give your rationale.

1. Urine output of 40 mL/hr
2. Cardiac index less than 2.4 L/min
3. Mean arterial BP is greater than 50 mm Hg
4. Left ventricular ejection fraction greater than 30%