Preoperative Nursing Care PDF

Preoperative Nursing Care Taking steps to educate, prepare, & reduce client anxiety extensively will improve postop outcomes ○ Benefits of good teaching: increases patient satisfaction; reduces postop fear, anxiety, & stress; decreases development of complications,...

Preoperative Nursing Care Taking steps to educate, prepare, & reduce client anxiety extensively will improve postop outcomes ○ Benefits of good teaching: increases patient satisfaction; reduces postop fear, anxiety, & stress; decreases development of complications, LOS, & recovery time ○ Initiated in surgeon's office, reinforced day of surgery ○ General surgery information is provided ahead of time; time to practice ○ Prioritize information after assessing the patient’s need ○ Document teaching to limit admissions & avoid duplications ○ Types of information to receive: Sensory: what they’ll see, feel, & hear before & after anesthesia Procedural: timing, restrictions, preparation, comfort measures, incision, TCDB, anesthesia, IV, site marking, Process: admissions, preop area, OR, PACU, overnight room, updating family ○ Responsibilities of preop nurse: what’s being done; why it’s being done (preop diagnostic testing results); associated risks/complications (comorbidities); coping skills; communicate & document data Surgical outcomes can be identified & often mitigated w/ a complete health history, ROS, & assessment ○ Subjective data: past health history → identify previous surgeries (drug reaction; problems w/ anesthesia); inquire about menstrual & OB hx; evaluate family hx (MH - genetic predisposition); take measures to prevent complications ○ Subjective data: medications → bring meds in original bottles; include all OTC meds - vitamins, herbs, supplements (can potentiate bleeding, BP, sedation, N/V); screen for potential issues (hypoglycemics, antihypertensives, opioids); discuss when to take or hold doses; inquire about substance use ○ Subjective data: allergies → inquire about allergies; document findings (mild, moderate, severe); apply allergy band; don’t forget food & environmental allergies (screen for latex allergy) ○ Review of systems (ROS): CV → HTN, angina, HF, MI, ICD, clotting disorder, artificial valve Preop 12-lead ECG, coagulation studies, antibiotic prophylaxis Resp → URI, asthma, COPD, tobacco use, sleep apnea Delay surgery, preop bronchodilator, monitor for hypoxemia, bring CPAP machine, baseline PFTs, smoking cessation (6 weeks) Neuro → stroke, TIA, SCI, parkinson’s, MS, myasthenia gravis  Establish their baseline for comparison postop GU → UTI, CKD, BPH, incontinence, pregnancy Risk for F&E imbalance, infection, impaired wound healing, impaired drug elimination; waterproof pad, coude catheter, renal panel; preop pregnancy test Hepatic dysfunction → jaundice, hepatitis, alcoholism, obesity Adverse response to drugs → detoxifictation of anesthesia; clotting abnormalities Integumentary → pressure ulcers, rash, breakdown, tattoos It affects wound/incisional healing, apply extra padding, select pigment-free areas - IV site Musculoskeletal → mobility problems, arthritis Influences positioning, intubation/airway management; incorporate mobility aids for safety Endocrine → diabetes (take ½ dose insulin before OR, frequent glucose checks, tight control); hypo/hyperthryroidism (manage metabolic rate, thyroid panel, thyroid management); addison’s disease (prevent addisonian crisis - additional IV corticosteroid during surgery (stress) Immune system → corticosteroid use; immunosuppression This leads to delayed healing & an increased risk of infection; cancel elective surgery if active infection is found; protective isolation measures Fluid & electrolyte status → diarrhea, bowel prep, vomiting, diuretics, fluid restriction BMP, risk for dehydration, IVF replacement Nutritional status → underweight/overweight (supplemental protein & vitamins to promote wound healing; extra padding on OR table to prevent skin breakdown); obesity (risk of heart/lung stress, wound dehiscence/infection, extra absorption of inhaled anesthesia; communicate BMI >40 (morbid obesity) - obtain bariatric bed & special equipment) A poor handoff or lack of effective communication across the perioperative phase can lead to errors & harmful events ○ Communicate timing w/ OR staff/transporter; ensure documentation is complete & patient is ready; communicate delays; ensure patient safety during transport (sedation onboard); SBAR hand-off & chart check; assist & inform family of waiting room procedures  Surgical patients need to be screened for malignant hyperthermia & pregnancy ○ Past health history: identify previous surgeries (drug reaction; problems w/ anesthesia); inquire about menstrual & OB hx; evaluate family health hx (MH → genetic predisposition); take measures to prevent complications ID & allergy bands are applied for patient safety ○ Inquire about allergies; document findings ~ mild, moderate, severe; apply allergy band; don’t forget food & environmental allergies Screen for latex allergy Nurses must advocate for the preop patient - be sure they have been well-informed by the surgeon ○ What is being done; why it’s being done (preop diagnostic testing results); associated risks/complications (comorbidities); coping skills; communicate & document data ○ Talk through what to expect; use familiar language; fear of death, pain, mutilation, anesthesia, disability (teach to stay on top of pain, listen to concerns) Ensure the consent form is accurate & signed ○ Requirements for surgical consent: adequate disclosure of diagnosis, risks, benefits, prognosis, clear understanding before sedation; given voluntarily - w/o persuasion or coercion ○ The surgeon is ultimately responsible for obtaining consent (nurses often act as a witness) ○ Be a patient advocate → notify physcian if the patient needs more info; withdraw consent at any time; qualified interpreter required when the ability to communicate effectively is questioned ○ Emancipated minors can sign consent ○ Legal representative or responsible family member may sign consent (minor, unconscious, mentally incompetent); consent may be overridden if medical emergy ~ requires documentation Preop nurses double-check that all provider orders have been carried out & the preop checklist is complete before transporting to the OR ○ Provide final teaching & complete baseline teaching; ensure completion preop orders & documentation ○ Complete preop checklist Verify consent is correct & signed; verify patient has been NPO; test results are present, verified & communicated; H&P is current; skin prep is done & surgical site is marked; makeup & nail polish are removed; patient ID & allergy bands are intact; dentures, contacts, glasses, jewelry are removed; preop meds  must be administered (benzodiazepines, anticholinergics, beta-blockers); IV antibiotics are ready to send w/ patient (given within 60 minute of incision); patient voided Comorbidities such as obesity, age, nutrition, infection, substance abuse & medical history carry an added risk for surgical patients ○ Already listed :) Intraoperative & Postoperative Nursing Care Several restrictions are in place to keep the surgical environment sterile and safe for patients ○ Unrestricted zone: public access; holding area; street clothes allowed ○ Semirestriced zone: corridors/staff support; authorized staff only; hospital laundered surgical scrubs, dedicated shoes/covers, hat - cover all hair; facial hair = mask ○ Restricted zone: operating rooms/sterile core; masks required around open sterile supplies Operative nurses communicate effectively w/ the surgical team & take several steps to protect patients from injury ○ Safety = teamwork & clear communication: SBAR ○ Surgical care improvement…initiative to prevent: Surgical site infections → prophylactic antibiotic within 30-60 min of incision Hypothermia → bear huggers/mistral warming blanket Venous thromboembolism → (SCD) ○ Time out & surgical checklist: pre-procedure verification process; H&P is current, consent is signed, assessments complete, diagnostic results, equipment is available Universal protocol → correct site, procedure, patient Surgical checklists, sterility, accurate sponge count ​needle counts, patient positioning, skin prep, maintaining normothermia, timely preop antibiotic administration, and fire risk assessment are all essential aspects of intraoperative nursing care ○ Circulator: non-sterile → maintain patient’s safety, dignity, confidentiality; distribute supplies, track progress, communicate, document; receive & give support ○ Scrub nurse: scrub in; set up sterile field, drapes; assist surgeon; supply count → along with circulating nurse ○ Nursing management during surgery setup: review the chart & get report; meet patient & address concerns; prep the room (privacy & safety; infection prevention; ensure equipment is ready & functioning; surgical scrub - “scrubber’; set up sterile table & count supplies); call for the patient; transfer the patient to the OR (ensure safe patient handling; place the patient on the monitor)  ○ Nursing management during surgery: assisting ACP (know effects of anesthetics, crash cart w/ emergency drugs, monitors, IV lines, make phone calls); positioning patient (follows induction of anesthesia; prone, lithotomy, supine, lateral; maintain alignment & prevent injury; secure extremities (padding, supportive wedges)) ○ Surgical site prep & safety considerations: prep the skin, clean to dirty; allow the skin prep to completely dry; drape around the incision site; if using cautery/laser → place grounding pad on well-vascularized muscle mass (thigh, bicep, low back - lateral); avoid excess hair, adipose/scar tissue, bony prominences; remove oxygen source & ventilate area before use Know the elements included in a surgical ‘time-out’ and understand their importance ○ Already listed :) Nurses must be aware of the level/type of anesthesia that is used, what patient assessments are expected, and what concerns need to be communicated ○ Local & regional (block): topical or injected; loss of sensation; inject into nerve group (plexus) - the risk of injecting in a vessel (systemtic spread = toxic) ○ Spinal (CSF) or epidural: subarachnoid space - total sensory/motor block; epidural space - more control & flexibility; monitor for decreased BP & HR, N/V, spinal HA, nerve injury, meningitis ○ Moderate sedation: administered IV by trained RN; twilight sleep/amnesia; midazolam (versed); patient maintains own airway ○ MAC (monitored anesthesia care): administered IV by anesthesia provider; deep sedation; used for procedures (scopes); risk loss of airway ○ General: administered in OR by the anesthesia provider; loss of sensation & consciousness; requires advanced airway management Screen patients for malignant hyperthermia before receiving general anesthesia, and know what manifestations to monitor for and what the treatment is ○ After exposure to an anesthetic agent; rare, genetic - screen every patient; causes hypermetabolism & catabolic processes (manifestations → muscle rigidity, hyperthermia, hypoxemia, lactic acidosis, hemodynamic instability); leads to cardiac arrest & death; treated w/ prompt administration of dantrolene Patients require significant monitoring after surgery. Nurses should know what factors put patients at risk, what assessments are important to make, what complications to monitor for, ways to prevent/treat/manage postop problems, and when it is necessary to contact the HCP ○ Respiratory complications: Airway obstruction → tongue occludes pharynx (reposition patient (lateral/sims vs increased HOB), head tilt/jaw lift  Hypoxemia → PaO2 < 60 mmHg (symptoms are nonspecific - agitation/somnolence, O2 sat < 92%; causes - atelectasis, pulmonary edema, aspiration; prevention - administer oxygen (eliminate anesthetic gases), incentive spirometer, TCBD) Hypoventilation → (symptoms - decreased RR/effort, hypoxemia, increased PaCO2 (hypercapnia); causes - depressed respiratory drive/muscle d/t anesthesia; prevention - assess the level of sedation before administering opioids ○ Cardiovascular problems: Hypotension → loss of volume; decreased organ perfusion; hypovolmic shock Treatments → apply oxygen, fluid resuscitation, assess bleeding, vasoconstrictive bleeding Hypertension → pre-existing condition; SNS triggers - pain, anxiety, bladder distension, respiratory distress, hypothermia Treat the cause Dysrhythmias → caused by - hypoxemia, hypercapnia, electrolyte or acid/base imbalance, hypothermia, medications Nursing management → ensure the patient can handle IVF rate & volume; cardiac monitoring; evaluate labs; trend VS; accurate I&O; early ambulation - increase HOB, dangle, chair ○ Neurologic & psychologic problems: Emergence delirium → wake up angry & confused Delayed emergence → wake up slowly The body doesn't process drugs efficiently, ex: renal disease Postop cognitive dysfunction & delirium → cognitive decline for weeks to months; more common in older clients or long/complicated surgeries Alcohol withdrawal delirium Nursing management → neuro assessment w/ comparison to preop; r/o hypoxemia 1st, then bladder distension & pain; consider reversing benzodiazepines & opioids (flumazenil & naloxone); keep patient safe & reorient; F&E balance; support family ○ Pain & discomfort: Increases risk for atelectasis & impaired respiratory function Nursing management → verbal pain is the most reliable; adapt care to meet individual needs & expectations; discuss pain control plan during report Medication management → multimodal analgesia (opioid + NSAID); time administration before activity; assess pain along w/ LOC using a sedation scale  Medication administration methods → PCA (continous infusion & self-administered bolus w/ lockout; epidural analgesia (delivers the drug to opiate receptors in the spinal cord via bolus, continuous infusion or PCA); perineural local anesthesia (non-opioid infiltrated into the surgical site; effective pain control x 72 hours) ○ Temp management: Frequent temp checks → q 15 min until normothermic, then 60 min; always use the same method Hypothermia → core body temp < 96.8; causes - skin exposure, irrigation solution, skin prep, inhlaed gases; risks - older females, epidural or spinal anesthesia, long case w/ open cavity; results in vasoconstriction, compromised healing, SSI; shivering consumes lots of oxygen; intervention - warming measures → circulating device, warm blankets, inline IVF warmer Fever → causes - SSI, pneumonia, UTI, C.diff, septicemia, MH; interventions - monitor/prevent/treat infection; cooling measures (>103) iced IV fluids, cooling catheter; dantrolene ○ Surgery-induced GI problems: Postop N/V - 80% Primarily affects young, female, nonsmokers w/ hx of motion sickness Constipation Anesthetics, immobility, opioids Postop ileus Impaired motility caused by bowel manipulation; small intestine ‘wakes up’ 1st; symptoms - cramps, distension, constipation, N/V Hiccups Phrenic nerve irritation stimulates the diaphragm Interventions Maintain F&E when NPO; delay postop intake; clear liquids first; antiemetics/stool softeners; frequent ambulation, right-side lying - assists in gas release; decompression - NG to suction ○ Urinary problems: Reduced UOP over 1st 24 hours postop is expected → caused by stress, preop fluid restriction, fluid loss Acute urinary retention is common after pelvic/lower abdominal pain → pain, guarding, pelvic muscle spasms all affect micturinition Oliguria caused by renal ischemia → d/t inadequate renal perfusion  Nursing management → remove indwelling catheter ASAP; if no void 6-8 hours postop; scan bladder & assess for distension; promote void - water stream, normal position, privacy, warm water over perineum ○ Integumentary problems: SSI (14-16% of HAI) → results in prolonged hospitalization, increased costs, and poor patient outcomes; noted on 3-5 postop day Impairs wound healing Prevent by adhering to SCIP guidelines → hand hygiene; prophylactic antibiotic administration; surgical site skin prep; maintaining normothermia; ensuring adequate nutrition Nurses need to know how to accurately assess and manage postoperative pain ○ Already listed :) Patients must meet certain criteria before they can be released from PACU or go home after surgery. Nurses should recognize when it is safe to discharge a postop patient ○ Moving out of recovery: when discharge criteria met → easily arousable; stable VS & O2 sat > 90%; no excessive drainage/bleeding; pain & N/V controlled; communicate w/ receiving unit; facilitate safe patient transfer; bedside using SBAR; assess → VS, sedation scale, lines/drains, pain, site, focused assessment; settle/safety/family; release/initate ‘return to floor’ ○ Discharged to home: Nurses should know what information is important to share when giving/receiving post-surgical bedside report ○ Already listed :) Pulmonary Disoders TB can lie dormant for years before producing illness ○ Dormant; may progress to active TB; bacteria can multiply months - years later; positive TB test; normal CXR; (-) sputum; asymptomatic; not transmissible; requires tx to prevent active TB Active TB is highly contagious and requires a care plan with added safety precautions ○ Aggressive management; a combination of 1st and 2nd line agents (4-5 drugs at a time; alter drugs based on sensitivity testing; initial phase (2 months) then continuation phase (6-9 months)); infectious for the first 2 weeks of treatment ○ Nursing management: assessment → assess transmission risk, immunosuppression, TB symptoms; analysis/dx → ineffective breathing, risk for infection, noncompliance, ineffective health management; planning → goals r/t compliance, reduce recurrence,  normal pulmonary function, take steps to prevent transmission; implementation → airborne precautions - negative air pressure room & N-95/respirator; initiate drug therapy; patient teaching ~ cough/sneeze etiquette (q 2-4 week sputums until at least 2 consecutive negatives; minimize exposure while infectious; importance of med compliance; reactivation of symptoms; notify public health department for follow up Acid-fast bacilli smears/cultures are monitored during active infection until 2 negative consecutive tests result ○ Sputum smear w/ (+) culture; other sites → gastric washings, CSF, fluid from abscess; diagnosis is definitive when culture is positive for M. tuberculosis ○ Q 2-4 week sputum specimens until at least 2 consecutive negatives Active TB treatment requires close adherence to a complicated drug regimen ○ Multi-drug resistant strain of TB: the organism is resistant to many first-line meds (clients become infectious again & transmit the drug-resistant bacteria to others ○ Directly observed therapy: watching patient swallow meds (public health measure d/t risk of reactivation w/ non-compliance ○ Isoniazid: may cause hepatotoxicity (avoid alcohol; monitpr LFTs q 2-4 weeks) ○ Rifampin: may interfere w/ contraceptives (oral; causes orange colored secretions that can stain) ○ Pyrazinamide: may increase uric acid levels (increase fluids to prevent gout & kidney problems) ○ Ethambutol: risk of eye problems & color changes; not for children (monitor vision) The treatment plan for pulmonary fungal infections (histoplasmosis) varies from other disorders ○ Pulmonary fungal infection caused by inhaling spores from contaminated soil; endemic - found in certain geographic locations (mid-southwestern) ○ Presents like bacterial pneumonia, dx is confirmed w/ blood test & CT of chest; not transmitted from person-to-person; systemic & acute histoplasmosis ~ tx w/ oxygen, IV amphotericin B & long course of PO antifungals (itraconazole) Diagnostic testing provides early diagnosis and implementation of an effective care plan to manage bronchiectasis ○ Diagnostics: CT scan of chest; sputum culture, PFTs, CXR ○ Treatment: prevent lung infection decline & tx flare-ups → antibiotics; bronchodilators & anticholinergics; hydration to thin secretions; airway clearance techniques; pneumonia & influence vaccines, reduce exposure to pollutants & irritants  Early and appropriate nursing actions are essential to caring for a client with dyspnea ○ Associated w/ poorer outcomes (ARF); assess respiratory acidosis & further hypoxemia; titrate oxygen ~ noninvasive mechanical CPAP or BiPAP ○ Pharmacologic treatments: short-acting bronchodilators; systemic corticosteroids; antibiotics (if the bacterial infection is caused) COPD is a common and irreversible disease classified by symptom presentation and stage of progression ○ Clinical manifestations: chronic intermittent cough; progressive dyspnea; chest heaviness; symptoms interfere w/ ADL; orthopnea; alveoli becomes overdistended; diaphragm flattens; air-trapping; ineffective breathing, use of accessory muscles; prolonged expiratory wheeze; decreased LS; barrel chest; pursed-lip breathing; upright position; hypoxemia (O2 sat < 88%); hypercapnia (PaCO2 > 45 mmHg); polycythemia & cyanosis (increased RBC production in response to chronic hypoxic state); increased pulmonary vascular resistance; pulmonary HTN (constricted pulmonary vessels; cor pulmonale → right ventricular hypertrophy (right side pressure increased to push blood into lungs Clients experiencing acute exacerbation of COPD manifest 3 cardinal symptoms ○ 3 cardinal signs: increased dyspnea, sputum, sputum purulence Clients with COPD require treatment plans that promote their oxygenation, breathing, airway clearance, and nutritional needs ○ O2 therapy: titrate per provider; humidification; CO2 narcosis → tolerate increased CO2 levels & hypoxemia = ‘drive to death’; O2 toxicity → prolonged exposure to high concentration of oxygen ~ inflammatory response, ARDS; infection → humidity supports bacterial growth ○ Breathing retraining: use of accessory muscle causes fatigue; abdominal breathing (focus on the diaphragm); pursed-lip breathing (prolongs exhalation); med therapy → bronchodilators, corticosteroids, mucolytics ○ Airway clearance techniques (ACT) - mobilize retained secretions: huff coughing (diaphragm breath, hold 2-3 seconds, forceful exhale); chest physiotherapy (percussion & vibration); postural drainage (drain into the larger airway; airway clearance device (flutter acapella)); high-frequency chest wall oscillation (inflatable vest & pulse generator)  ○ Nutritional therapy: combat weight loss; schedule meals 1 hour before/after therapies; extra protein & calories; dietician consult; fluids to thin secretions; pulmonary rehab → exercise training; smoking cessation; nutrition counseling; health education Vascular Disorders PAD presents as limb ischemia, claudication pain, pallor/rubor & cool skin, diminished pulses, necrotic ulcers, shiny & dry skin with sparse hair growth & thickened nails ○ Treatment is focused on restoring arterial blood flow It depends on site & extent of blockage, amount of blockage, amount of collateral circulation → brought on by exercise, resolves w/ rest, reproducible Neurosensory impairment: N/T; thin, shiny, taut skin; loss of hair on affected extremity; thickened toenails; diminished/absent pulses; pallor w/ elevation; rubor w/ dependent positioning; rest pain ~ indicated significant blockage Complications of prolonged ischemia: atrophy of skin & underlying muscles; tissue necrosis; arterial ulcers are bony prominences (delayed wound healing; wound infection; gangrene); tx options → collateral circulation vs revascularization vs amputation Treatment: surgical revascularization via bypass w/ naive vein Non-surgical → peripheral angiogram w/ intervention (balloon angioplasty, stents, artherectomy, cryoplasty) Conservative approach → protect extremity (heel protectors); control infection (skincare & sterile dressings); reverse Trendelenburg (decrease pain & increase perfusion - control pain); amputation (tissue necrosis, gangrene, osteomyelitis) Venous insufficiency presents as dependent pain and edema; itchy, dry, leathery, brownish skin discoloration & venous stasis ulcers ○ Treatment is focused on getting blood flow back to the heart Edema; skin changes; hemosiderin deposits → brownish discoloration/leathery appearance; venous stasis ulcers = lower leg, ankle/irregular shape Complications: achy, dull pain; heaviness; worse in dependent position; dermatitis - itchy; cellulitis Treatment: compression; wound care; nutrition; assess for infection; med → inflammation & edema; elevate legs → decrease edema; skin moisturizer to prevent cracking of skin  PAD patients require antiplatelet therapy and CVD risk factor modification ○ Drug therapy: decrease CVD events & mortality rate; antiplatelets → ASA & Plavix; Phosphodiesterase Omeprazole decreases the effectiveness of Plavix by ½ ABI assessments are used to determine the severity of PAD. A normal ABI reading is 1.0 -1.4. ○ Assess strength of peripheral pulses (palpate or doppler assisted); ABI → cornerstone of PAD diagnosis Normal: 1.00 - 1.30 Borderline: 0.91 - 0.99 PAD: 100.4; dx → assessment paired w/ D-dimer & duplex ultrasound The 6 P’s signify inadequate tissue perfusion and require immediate provider notification ○ Pain, pallor, pulselessness, paraesthesia, paralysis, polar Enoxaparin (Lovenox) and warfarin (Coumadin) are anticoagulants for VTE prophylaxis in high-risk patients. Early ambulation, TED hose, and SCDs can prevent clot formation ○ Warfarin: po; monitor PT/INR; adjust dosing to achieve therapeutic level (20-30); takes time to be effective; reverse w/ vitamin K ○ Heparin: SQ or IV; monitor PTT; reverse w/ protamine sulfate; watch for HIT (thrombocytopenia) ○ Dabigatran: po; not reversible ○ Enoxaparin: SQ; weight-based; fast acting; no labs to monitor ○ Rivaroxaban: po & SQ; standardized dosing; no labs to monitor ○ Early ambulation (aggressive); position changes, flexion, extension exercises; TED hose; SCDs (don’t use if patient has a thrombus); teach s/s of PE  Aortic aneurysms run the risk of rupture based on size. Timely assessment and management is crucial to save the patient’s life ○ Smoking increases growth; size increases rupture risk ○ Clinical manifestations: thoracic (ascending & arch) → cough,mSOB, hoarse voice, dysphagia (pressure on laryngeal nerve); JVD, face/arm edema (r/t pressure on SVC); deep, diffuse CP - extends beyond shoulder blades; abdominal → pulsatile mass/bruit’ back pain r/t compression ○ Complications: rupture; s/s → severe back pain, flank ecchymosis (grey-turners sign); umbilical ecchymosis (cullen’s sign); internal hemorrhage → shock → death ○ Early detection & prompt tx to prevent rupture = based on diameter Grafts are used to repair an aneurysm. Nurses need to monitor for postop complications and keep BP within range ○ Graft patency: BP → too low = graft migration & thrombosis; too high → rupture or leak; peripheral perfusion → assess pulses - CSM (circulation, sensation, movement); monitor for thrombosis; renal perfusion → I&O; BUN/Crt; hydration; AKI monitoring; discharge care → avoid heavy lifting, teach assessment; males may have ED Stroke Disorders The FAST scale is used to teach recognizable stroke signs ○ F: face ○ A: arm ○ S: speech ○ T: time to call Primary stroke prevention is focused on reducing modifiable risk factors ○ TIA: HTN; DM; smoking; CAD; oral contraceptive; sedentary lifestyle ○ Subarachnoid hemorrhage: high blood pressure; smoking; African Americans; Latino’s; excessive ETOH; SNS drugs; family hx (autosomal dominant PKD; type 5 Ehler’s Danlo’s syndrome; aSAH); age (men → 25-45 & > 85) (women → 55-85) ○ Intercerebral hemorrhage: HTN; ETOH; vascular misinformations; amyloid angiopathy; coagulopathies (anticoagulants/antithromb; fibrinolysis; cirrhosis) ○ Ischemic → HTN; high blood cholesterol; DM; smoking; sedentary lifestyle; carotid or other artery artery disease; atrial fibrillation Clinical manifestations are based on the type of stroke (ischemic vs hemorrhagic) and the location of the stroke ○ Hemorrhagic: intercerebral hemorrhage → bad (sudden focal neurological deficit; headache); worse (n/v; decreased LOC); really bad (increase BP; seizures) ○ Ischemic: abrupt onset; focal weakness; speech disturbance; often wakes up w/ symptoms (suggests these strokes have increased incidence during sleep) ○ Left cerebral hemisphere stroke: left = language Spoken/written language, reasoning, number skills Aphasia Receptive → understanding Expressive → responding Dysarthria Slurring d/t impairment of tongue or other speech muscles Impaired comprehension Adding numbers, balancing a checkbook, counting charge Right hemi-neglect/hemiplegia Slow & cautious behaviors Will need more coaching to feel safe w/ activities Transferring to bed/chair Defects in the right visual fields Left gaze - towards the side of the injury ○ Right cerebral hemisphere: right = reckless Artistic abilities → music, creativity, spatial orientation Left hemiplegia/hemi-neglect Behavioral changed Inability to recognize body parts Inappropriateness Impulsive Short attention span Right gaze deviation - look to the side of the injury ○ Cerebellum/brainstem stroke Dizziness Dysarthria Dystaxia Diplopia Dysphagia  Loss of coordination (gait imbalance, bowel/bladder control, HA, N/V, vertigo) ○ Braintesm stroke: Irregular RR, BP, HR Death if swelling Coma Horner’s syndrome Inability to control temp Loss of airway Hiccups, tinnitus Dysphonia (weak/wet sounding voice) Dysphagia Knowing the time of symptom onset is crucial to the interprofessional management of stroke ○ First 24 hours: stroke symptoms can evolve over minutes to hours; 30% of stroke survivors will deteriorate in 1st 24 hours; stroke can mimic → bell’s palsy; hypoglycemia; complex migraine; brain tumor; conversion disorder ○ ED care resolves around: dx of type (ischemic vs hemorrhagic); eligibility for IV alteplase (exclusion vs inclusion criteria); IV alteplase window up to 4-5 hours from onset of symptoms Patients must be kept NPO until dysphagia is ruled out ○ 30-50% of stroke pts will have a swallowing deficit; not just for stroke patients - applies to any patient at risk for aspiration; 2 steps → give 1 tsp of WATER; if no choking, gurgling, coughing - give 3 oz w/o interruption; if patient doesn’t exhibit symptoms - then may take oral meds/nutrition; if patient exhibits signs of choking, gurgling - keep NPO until further eval by speech therapist Rehabilitation begins in the acute care phase and is essential to maximize the patient’s abilities ○ Preventing recurrence: lifestyle changes; meds; smoking cessation; recovery goals ○ Core measures for stroke: VTE prophylaxis within 24 hours; discharged on an antithrombotic; anticoagulation for a-fib/flutter; antithrombic end on day 2; discharged on statin; stroke education; assessed for rehab; swallow screening An ischemic stroke is classified as thrombotic or embolic while a hemorrhagic stroke can be intracerebral or subarachnoid  ○ Ischemic: oxygen-rich blood flow to the brain is restricted by blood clot/other blockages; embolic event → a-fib; dissection; prosthetic valves; clot in the ventricle; cardiomyopathy; endocarditis ○ Hemorrhagic: subarachnoid → in arachnoid space; intrecerebral → within brain Chronic Neurological Disorders Clients with ALS are fully aware and eventually rendered immobile ○ Nervous system disease that weakens muscles & impacts physical function ○ Neurons die - no longer transporting signals to muscles ○ Marked by progressive muscle weakness & atrophy Starts w/ clumsiness, tripping, twitching Progressive neurological degeneration is common in MS, Parkinson’s, ALS, & Huntington’s ○ MS: chronic, progressive & degeneration CNS disorder; the immune system attacks the protective sheath that covers nerve fibers (demyelination); leads to communication problems between the brain & the rest of the body ○ Parkinson’s: disorder of the CNS that affects movement; affects the brain’s production of dopamine & ability to relay messages ○ ALS: already listed :) ○ Huntington’s: inherited condition in which nerve cells in the brain break down over time; uncontrolled movements, emotional problems, loss of cognition Clinical manifestations are based on the disease process and vary between disorders ○ Headache: tension (bandlike, tightening; photo/phonophobia; neck muscles); migraine w/ or w/o aura (unilateral, pulsating, lasts 4-72 hours): cluster (sharp/stabbing, minutes to 3 hours) ○ Epilepsy: look @ ATI ○ Restless leg syndrome: n/t “pins & needles”; severe pain in calves; sensations “bugs crawling”; disrupted sleep; daytime fatigue; involuntary movements during sleep; relief w/ physical activity ○ MS: 5 Stages: Mild to Debilitating; difficulty swallowing and speaking; shuffled gait;; bradykinesia: slowed movement; depression, anxiety, apathy; Memory changes; restless sleep ○ MG: diplopia; ptosis; problems speaking; eating; breathing ○ ALS: starts with ‘clumsiness’, tripping, twitching ○ Huntington’s: uncontrolled movements, emotional problems, loss of cognition  Nurses should be able to distinguish between assessment data that is considered ‘normal’ with a disease process and signs of complications ○ Already listed :) Teach clients with chronic neuro disease how to recognize and prevent complications, as treatment options are typically not available ○ Status epilepticus: IV Meds for status epilepticus: lorazepam (Ativan) & diazepam (Valium) ○ Restless leg syndrome: r/o Secondary Causes: serum ferritin, CBC, renal function (cr); eval for conditions that may worsen symptoms → pregnancy; anemia; DM (peripheral neuropathy) ○ MS: avoid exacerbation triggers: infection, trauma, hot/cold extremes Treatment: immunomodulator per self-injection & immunosuppressants ○ Parkinson’s: falls; constipation; confusion, wandering; dysphagia/aspiration; dyskinesias (involuntary movements) Medications: levodopa with carbidopa (Sinemet) – monitor for side effects and interactions! Deep brain stimulation; prioritize safety ○ MG: acute myasthenic crisis Maintaining adequate ventilation Anticholinesterase agents, immunosuppressive agents, corticosteroids Schedule medications to peak effectiveness at mealtime ○ ALS: death often results from respiratory tract infection Reducing the risk of aspiration ○ Huntington’s: patients may need 4000- 5000 calories/day to maintain due to the involuntary extra movements (chorea) – harder to achieve as the disease progresses Tonic-clonic seizures require intervention by caregivers to ensure the proper monitoring and client safety is maintained ○ Clients experiencing a tonic-clonic seizure present with alternating tonic movements and clonic movements. The client also temporarily loses consciousness during the seizure. Upon awakening, the client may be confused and experience headaches and sleepiness. Although rare, clients may also experience generalized seizures that involve only tonic or clonic movements. Removal of triggers can prevent some chronic neuro conditions from manifesting  ○ Headache: triggers: Chocolate, cheese, red wine, menstruation, head trauma, exertion, fatigue, stress, missed meals, weather, drugs ○ Epilepsy: not triggers, but causes → structural injury, infection, trauma, genetic factors, brain tumor, vascular disease, stroke, idiopathic generalized epilepsy (IGE) 1/3 of all cases ○ Restless leg syndrome: pregnancy, anemia, DM (peripheral neuropathy) ○ MS: may be precipitated by a virus; more common in women; avoid infections, trauma, hot/cold extremes ○ Parkinson’s: no known cause or cure; more common in men ○ MG: autoimmune disease ○ ALS: reduces aspiration & decreases risk of respiratory illness ○ Huntington’s: inherited condition in which nerve cells in the brain down over time Goals for clients with progressive neurological disease processes are focused on maintaining safety, reducing complication risk, and maintaining function for as long as possible ○ Headache: Planning aimed at reducing or eliminating pain, understanding triggers and treatment, positive coping strategies/quality of life Implementation: stress management, comfort measures, quiet/dim environment, analgesics, teach dietary triggers, keep track of last doses of medications – prevent overdose Medication management: OTC pain relievers: NSAIDS, Acetominophen, ASA Vasoconstrictors: caffeine, triptans (Imitrex) – given at onset of migraine or cluster HA ○ Available in oral, injection, nasal spray & transdermal Preventative treatment options: Pharmacological: anticonvulsants (Topamax), beta-blockers, tricyclic antidepressants, botox injections Non-pharmacological: hydration, low nitrate/MSG diet, biofeedback, massage, acupuncture ○ Epilepsy: Antiseizure medications → therapeutic range to minimize toxic side effects while preventing seizures; teach medication compliance & restart seizure medications ASAP; may require combination therapy to be effective; primarily  used: phenytoin (Dilantin), carbamazepine (Tegretol), phenobarbital, clonazepam (Klonopin), levetiracetam (Keppra) Health promotion → use caution with dangerous activities; taking baths, swimming alone; driving laws; avoidance of triggers; medication regimen; medical alert bracelet Acute care interventions → adhere to seizure precautions – protect from injury; maintain airway, side-lying, protect head; do not restrain; loosen clothing; monitor and document (duration of seizure activity; body movement – type, character & progression; incontinence of bowel or bladder); after seizure -- suction, oxygen, reorient ○ Restless leg syndrome: Treatment → eliminate aggravating factors: alcohol, caffeine, meds; treat underlying cause; meds: carbidopa/levodopa, ropinirole (Requip); daily exercise; iron supplement; relaxis Device: vibration therapy to diminish symptoms ○ MS: Medications → immunomodulators per self-injection & immunosuppressants Implementation → revent complications of immobility; educate on self catheterization; increase fiber intake; energy conservation measures; assess need for assistive devices; caregiver & emotional support; resources - PT/OT/SLP ○ Parkinson’s: Medications to correct the imbalance of CNS neurotransmitters Levodopa with carbidopa (Sinemet) – monitor for side effects and interactions! Implementation → adaptations that promote independence w/ self care activities; promote exercise to decrease atrophy, contractures, constipation; PT/OT; speaking & swallowing, gait & coordination; manage sleep problems; prevent injury & aspiration; address communication barriers ○ MG: Nursing interventions → maintain adequate ventilation; anticholinesterase agents, immunosuppressive agents, corticosteroids; semi-solid foods may be easier to swallow; schedule medications to peak effectiveness at mealtime; plan ADLs to avoid fatigue ○ ALS:  Nursing implementation → facilitating communication; reducing the risk of aspiration; assessing for complications from immobility; decreasing the risk of injury & respiratory illness; supporting cognitive & emotional support ○ Huntington’s: Patients may need 4000-5000 calories/day to maintain due to the involuntary extra movements (chorea) – which are harder to achieve as the disease progresses Headaches and seizures are classified based on location and clinical presentation ○ Headaches: tension (bandlike, tightening; photo/phonophobia; neck muscles); migraine w/ or w/o aura (unilateral, pulsating, lasts 4-72 hours): cluster (sharp/stabbing, minutes to 3 hours) ○ Epilepsy: look @ ATI