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During the visit discount 2.5mg plendil otc hypertension management guidelines, the nurse assists the patient and family with wound care and exercises cheap plendil 2.5mg online blood pressure heart rate. Patients with severe or persistent depression or difficulty adjusting to changes in their social or occupational roles are identified and referred to the burn team for possible referral to a psychologist, psychiatrist, or vocational counselor. The burn team or home care nurse identifies community resources that may be helpful for the patient and family. Several burn patient support groups and other organizations throughout the United States offer services for burn survivors. They provide caring people (often people who have themselves recovered from burn injuries) who can visit the patient in the hospital or home or telephone the patient and family periodically to provide support and counseling about skin care, cosmetics, and problems related to psychosocial adjustment. Such organizations, and many regional burn centers, sponsor group meetings and social functions at which outpatients are welcome. Some also provide school-reentry programs and are active in burn prevention activities. Therefore, the patient and family are reminded of the importance of periodic health screening and preventive care (eg, gynecologic examinations, dental care). Tomography and ultrasound may also be used 334 Surgical Treatment: Scleral Buckle Trauma • Prevention of injury • Patient and public education • Emergency treatment –Flush chemical injuries –Do not remove foreign objects –Protect using metal shield or paper cup Protective Eye Patches 335 Chapter-60-Assessment-of-Neurologic-Function The Human Nervous System • Its purpose is to control all motor, sensory, autonomic, cognitive, and behavioral activities. The Nervous System: Structure • The nervous system is divided into: –The central nervous system, consisting of the brain and spinal cord. The Brain • Composed of gray matter and white matter, the brain controls, initiates, and integrates body functions through the use of electrical impulses and complex molecules. The Brain Hemispheres • The right side receives information from and controls the left side of the body. Specializes in perception of physical environment, art, music, nonverbal communication, spiritual aspects. Specializes in analysis, calculation, problem solving, verbal communication, interpretation, language, reading, & writing. Cerebrospinal Fluid • Provides for shock absorption and bathes the brain and spinal cord. Peripheral Nervous System: Cranial Nerves • Twelve pairs of cranial nerves have sensory, motor, or mixed functions. Neurologic Assessment: Health History • Pain • Seizures • Dizziness (abnormal sensation of imbalance or movement) and vertigo (illusion of movement, usually rotation) • Visual disturbances • Weakness • Abnormal sensations Neurologic Assessment • Cerebral function; mental status, intellectual function thought content, emotional status, perception, motor ability, and language ability –Note the impact of any neurologic impairment on lifestyle and patient abilities and limitations –Agnosia is the inability to interpret or recognize objects seen through the special senses. The patient stands with feet together and arms at the side, first with eyes open and then with both eyes closed for 20 to 30 seconds. The examiner stands close to reassure the patient of support if he or she begins to fall. Slight swaying is normal, but a loss of balance is abnormal and is considered a positive Romberg test. Figure Used to Record Muscle Strength • 5, full range of motion against gravity and resistance; 4, full range of motion against gravity and a moderate amount of resistance; 3, full range of motion against gravity only; 2, full range of motion when gravity is eliminated; 1, a weak muscle contraction when muscle is palpated, but no movement; and 0, complete paralysis. The cause may be neurologic (head injury, stroke), toxicologic (drug overdose, alcohol intoxication), or metabolic (hepatic or renal failure, diabetic ketoacidosis). Nursing Process: The Care of the Patient with Altered Level of Consciousness— Assessment • Assess verbal response and orientation • Alertness • Motor responses • Respiratory status • Eye signs • Reflexes 343 • Postures • Glasgow Coma Scale Decorticate and Decerebrate Posturing Abnormal posture response to stimuli. Maintaining fluid status –Assess fluid status by examining tissue turgor and mucosa, lab data, and I&O. Promoting Bowel and Bladder Function • Assess for urinary retention and urinary incontinence • May require indwelling or intermittent catherization • Bladder-training program • Assess for abdominal distention, potential constipation, and bowel incontinence • Monitor bowel movements • Promote elimination with stool softeners, glycerin suppositories, or enemas as indicated • Diarrhea may result from infection, medications, or hyperosmolar fluids 346 6. Monitor I&O, weight, blood glucose, serum and urine electrolyte levels, and osmolality and urine specific gravity. The patient is asked to identify the day, date, or season of the year and to identify where he or she is or to identify the clinicians, family members, or visitors present. The nurse assesses for periorbital edema (swelling around the eyes) or trauma, which may prevent the patient from opening the eyes, and documents any such condition that interferes with eye opening. Motor response includes spontaneous, purposeful movement (eg, the awake patient can move all four extremities with equal strength on command), movement only in response to painful stimuli, or abnormal posturing (Hickey, 2003; Seidel, Ball, Dains, et al.
If the carotid artery is of reasonable diameter buy plendil 5 mg line pulse pressure 37, some surgeons advocate primary closure order plendil 5 mg without a prescription blood pressure 220 120. Again, good results have been docu- mented using any of a number of closure techniques. Surprisingly, the vast majority of patients tolerate having their carotid artery clamped for the period of the surgery. There is a small subset of patients who do not tolerate any significant period of cerebral ischemia. Primary preven- tion of ischemic stroke: a statement for healthcare professionals from the Stroke Council of the American Heart Association. Preventing ischemic stroke in patients with prior stroke and transient ischemic attack: a statement for healthcare professionals from the Stroke Council of the American Heart Association. Supplement to the guidelines for the management of transient ischemic attacks: a statement from the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks, Stroke Council, American Heart Association. Prevention of a first stroke: a review of guidelines and multidisciplinary consensus statement from the National Stroke Association. After adequate exposure is achieved, the internal, external, and common carotid arteries are clamped (A). A plane of dissection is created between the arterial wall and the atheromatous process (B). After the plaque is transected proximally, it can be reflected upward to aid in the distal portion of the endarterectomy (C). After completion of the endarterectomy, any remaining loose pieces of atheroma or strands of media are removed (D). Medial and adven- titial layers of the internal carotid artery are everted over the atheromatous core (B). There are many different types of shunts, but they all are some form of plastic tubing that is placed within the lumen of the carotid artery and maintains cerebral blood flow during the operation. The surgeon can perform the operation under a regional anesthetic and selectively shunt only those patients who have a neurologic change upon carotid clamping. Shunting generally is recommended if the carotid stump pressure falls below 45 to 50mmHg. Patients who have a carotid endarterectomy generally do ex- ceedingly well postoperatively. They must be watched closely for bleeding, acute neurologic change, hypertension, hypotension, cardiac problems, and signs of cranial nerve injury. They generally are followed periodically with carotid duplex scans to check for restenosis of the operative side and to evaluate the contralateral side. Carotid Angioplasty and Stenting As in most aspects of vascular surgery, endovascular techniques are being employed in the hope of decreasing patient discomfort, hos- pital length of stay, requirements for general anesthesia, and scar- ring. There are encouraging data for and a growing experience with balloon angioplasty for carotid stenosis. The overall experience, however, has resulted in a higher procedural stroke rate compared to open surgery, with no significant decrease in length of stay and with increased costs. With increased experience and with the advent of cerebral protection devices, the outcomes may improve. There currently are several ongoing multicentered clinical trials designed to compare the results of carotid angioplasty to open surgery. The results of these trials will clarify the role of carotid angioplasty in the future. Case Conclusion The patient in the case at the beginning of this chapter presents with signs and symptoms that certainly could be attributed to atheroscle- rotic disease at the carotid bifurcation. After a thorough history and physical and particularly if he has a carotid bruit, he would benefit from a carotid duplex exam. If that reveals significant stenosis greater than 70%, then surgical correction of the lesion should be considered. Summary Stroke as a consequence of cerebral vascular disease is very prevalent, and, as the population continues to age, it most likely will become increasingly common. As a physician or healthcare provider, one must be aware of the pathophysiology as well as of the risk factors that may increase a patient’s risk of stroke. The signs and symptoms of cerebral vascular disease have been discussed in detail in this chapter.
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