Unit 5 Neurological Function Alteration PDF

UNIT 5 Alteration in Neurological Function Neuro assessment Symptoms  Complaints o Pain o Seizure o Dizziness/ vertigo o Visual disturbance o Muscle weakness o Sensation changes  Physical findings o Alertness/ LOC...

UNIT 5 Alteration in Neurological Function Neuro assessment Symptoms  Complaints o Pain o Seizure o Dizziness/ vertigo o Visual disturbance o Muscle weakness o Sensation changes  Physical findings o Alertness/ LOC o GCS- eye opening, verbal, motor (3-15) o Thought content o Language o Emotional control o Motor function o Sensory perception Neuro diagnostic assessment  VS & ECG  CT- computed tomography scan o CT-A- CT angiography  MRI- magnetic resonance imaging o MR-A- magnetic resonance angiography  Cerebral angiogram  Carotid ultrasound  Echocardiogram  Lumbar puncture  Blood work o Lipids, clotting factors  Antiphospholipid, Factor V, Antithrombin III Acute Disorders of the brain  Cerebrovascular disease & Stroke o Risk factors  Ischemic event  Anticoagulant use  DM  High cholersterol  Oral conttraceptives   Carotid artery disease  Physical inactivity  Obesity  Afib  Smoking  Stress  Hemorrhagic event  Hypertension  Anticoagulation therapy  Obesity  Excess alcohol intake/ drug use  Stress  Trauma o Stroke (CVA)/ TIA findings  Acute/ unilateral  Lethargic  Obtunded  Numbness  Weakness/ hemiparesis  Paralysis/ hemiplegia  Hemianopsia- loss of half of vision field  Agnosia- inability to recognize objects  Dysarthria- difficulty forming words  Apraxia- inability to perform familiar tasks  Ataxia- unsteady gait  Neglect  Aphasia  Expressive  Receptive  Global  Emotional change  Behavioral change  Cognitive change o TIA/RIND  Presents as stroke  Neurological deficits o Motor/sensory/visual  Neuro assessments  GCS/ symptoms  Symptoms resolve  1-2 hours  Ischemia, not infarct  Precursor to ischemic stroke  Diagnosis   Non-con CT  Carotid US, ECG, CT-A  Management  Assess (symptoms, full neuro, GCS)  Identify cause (BP, arteries, spasms)  Decrease risk o Manage HTN/ cholesterol/ CAD  Patient education Ischemia stroke vs. bleeding  Ischemic Stroke o Blockage o Thrombotic/ embolic o Assessment/ nursing  GCS  FAST  NIHSS o Diagnosis  Report any symptoms  LKW or LSN (last know well/ last seen normal)  Non-Con CT  30 minutes  Additional testing (MRI, MR-A, CT-A) o Management  Assess/ stabilize*  tPA*- tissue plasminogen activator  page 2015 chart 67-3  screening/ inclusion/ exclusion (next slide)  3-4.5 hours of symptom onset  Within 60 minutes of arrival in ED  Weight based/ 1 min/ 60 min   Manage complications  Airway/ O2  Cardiac/ ECG  (later) immobility o Bowel/ bladder  UTIs, incontinence, stool softeners (Dulcolax) o TPA V. No TPA management  TPA  BP control (lower)  Bleeding consideration  Expectations  Very frequent VS/ assessment  No tPA/ >24 hours post tPA  Consider alternative medication therapies o Antiplatelets (ASA, clopidogrel) o Anticoagulants (warfarin, heparin, enoxaparin) o Antihypertensives (MD choice) o Statins (rosuvastatin, atorvastatin) o Nursing interventions for ischemic stroke patient  NIHSS  Frequent neuro assessments, frequency depends on treatment  Swallow evaluation  TORBSST, Toronto bedside swallowing screening test  Monitor/ assess/ prevent complications  Exercise, turning, repositioning, mobility, self-care, bowel and bladder, sexual dysfunction  Maintain medication administration regimen  Consult- nutrition, PT/OT, neurology  Monitor cardiac rhythm & vitals (BP, O2)  PRN oxygen therapy, BP controlled based on treatments  Patient and family education  Max functional status  6 months o Nursing diagnosis  Impaired swallowing  Impaired speech  Ineffective health maintenance  Risk for impaired skin/ imbalanced nutrition: less than  Self-care deficit  Constipation  Impaired urinary elimination  Impaired comfort  Sexual dysfunction  Incontinence  Social- interrupted family process  Knowledge deficit  Risk for injury  Ineffective maintenance Hemorrhagic Stroke  Intracerebral  Subarachnoid  Cerebral aneurysm  Vessel malformation- AVM  Assessment o Exploding HA/ “thunder clap” HA o PLUS s/s of ischemic stroke o Monitor for increased ICP- worsening HA, pupils  Diagnostics o Same as ischemic stroke  Management (tx the cause!) o Generally, like an ischemic stroke PLUS o Minimize risk for further bleeding  NO TPA!!  BP goals  Correct over anticoagulation  Vitamin K, protamine sulfate, idarucizumab, KCentra o Decrease intracranial pressure  Stimulation/ sedation/ anxiety  Osmotic diuresis  Stool softener o Seizure management  Lorazepam, phenytoin  Seizure precautions o NPO, until swallow evaluation is completed  Nutritional consult o Strict BP management o ICP monitoring  Environment and interventions  Quiet, non-stimulating environment  Anxiety/ sedation  Signs of complications  Vasospasms o HOB elevated 30 degrees o Neurological consult o Surgical intervention  Pre/post-operative care  Craniotomy  Ventricular drain o Possible administration of blood products  Anticoagulant reversal General Stroke: Planning and Interventions  IV fluids (normal saline or LR)/ medications  Nutrition o Swallowing assessment o Dietary evaluation o Calorie counts  Assess temperature o Treat if greater than 99 F  Assess blood glucose levels as prescribed  Rehab consults as soon as possible/ consider home care o Patient/ family education  Assess for signs of iICP/ neuro decline  Accommodate limitations (assistive devices)  Prevention of complications o Establish exercise programs, turn frequently (skin), enhance self-care, bowel and bladder programs, help patient cope with sexual dysfunction. Client teaching- alterations in function  An occupation therapist can point out techniques that make daily activities easier o Lay clothes nearby o Slip on, elastic Velcro  Allow plenty of time so that patient doesn’t feel rushed  ROM/ PT/OT/ ambulation  If patient has difficulty swallowing o Thickened liquids o Soft foods that have stickiness (mashed potatoes or macaroni & cheese) o Avoid straws Cerebral Aneurysm  Assessment o Same as stroke  Can lead to hemorrhagic stroke  Diagnosis o CT brain/ head/ neck o MRI brain/ head/ neck o CT-A  Medical management o Locate aneurysm o Monitor for growth or changes (serial CTs or MRIs) o Surgical interventions  Nursing intervention/ nursing diagnoses  o Nonbleeding aneurysms- BP management, ongoing evaluation, surgical intervention o Bleeding aneurysms- hemorrhagic stroke Arteriovenous malformation  Assessment o Usually found via MRI o Headaches  stroke  Medical management o Locate AVM o Monitor for bleeding o Monitor for changes  Nursing interventions o Same as aneurysm OR same as hemorrhagic stroke o Postoperative care  Diagnosis o Knowldeg deficit o Risk for injurt o Ineffective health maintenance o Impaired swallowing o Impaired speech o Risk for impaired skin integrity o Self care deficits o Constipation o Impaired urinary elimination o Impaired comfort o Sexual dysfunction o Socia- interrupted family processes More nursing diagnoses for stroke patients  Risk for Impaired gas exchange  Risk for aspiration  Impaired physical mobility  Impaired social interaction  Impaired swallowing  Ineffective Tissue Perfusion  Disturbed Sensory Perception  Impaired health maintenance  Sexual dysfunction  Constipation  Impaired urinary elimination  Impaired verbal communication  Anxiety  Risk for injury & falls   Ineffective coping  Interrupted family processes  Risk for impaired skin integrity  Self-Care Deficit  Unilateral Neglect  Total Urinary and Bowel Incontinence Seizures Seizures Disturbances in normal brain function Abnormal electrical signals Hyperactivity LOC Motor Sensory Epilepsy = recurring Partial (localized & focal) or generalized Where it begins Where it goes Partial  generalized Risk factors Family history Stroke/ cerebral vascular disease Environment Sleep Electrolytes/ pH Stress Head injury/ i-ICP Meningitis/ infection Neurosensory overload Flashing lights, video games and prolonged television viewing Assessment Findings/ presentation dependent on cerebral area affected Aura Seizure characteristics Precipitating event Decreased LOC Shaking Unintelligible talking  Dizzy spell Incontinence Twitching/ muscle activity (repetitive) Tongue biting/ jaw clenching Post ictal phase (expectations/ education) Diagnostic tests Electroencephalogram (EEG) Computerized tomography (CT) Magnetic resonance imaging (MRI) Positron emission tomography (PET) uses a small amount of low-dose radioactive material intravenous visualize active areas of the brain and detect abnormalities Single-photon emission computerized tomography (SPECT) - small amount of low-dose radioactive material injected into a vein to create a detailed, 3-D map of the blood flow activity in the brain during seizures Planning and interventions Priorities Prevent/control Protect Airway/respiratory Physical Promote Self-esteem Provide Information Generalized Seizures  Involves entire cortex  Absence seizures- AKA petit mal o Staring or subtle body movement, brief loss of consciousness  Myoclonic seizures o Sudden jerks or twitches of arms and legs  Atonic seizures- AKA drop attacks o Loss of normal muscle tone, suddenly collapse or fall  Toni-clonic seizures- AKA grand mal o Most intense of all types of seizures o Loss of consciousness, intermittent stiffening and shaking, loss of bladder control. Partial seizures vs. generalized seizures  Abnormal activity in just one part of the brain vs. abnormal activity of full cortex  Simple partial seizures o No loss of consciousness  o May alter emotions or sensory (look, smell, feel, taste, or sound) o May result in involuntary jerking of part of the body, such as an arm or leg. o Sensory symptoms such as tingling, vertigo, and flashing lights  Complex partial seizures o Always alter consciousness o Result in starting and/or non-purposeful movements- such as hand rubbing, twitching, chewing, swallowing or walking in circles  Generalized seizures o Always alter consciousness o Result in non-purposeful & sometimes violent motor activity (convulsions) Nursing care of the seizing patient  Be prepared/ plan ahead  Pre-ictal phase o Circumstances o Aura o Triggers  Ictal phase o Safety  Floor/bed  Loosen clothing  Move furniture  Pillows/ side rails  DO NOT OPEN MOUTH  DO NOT RESTRAIN o Seizure characteristics  Length  Type  LOC/cognition o Privacy  Post-ictal phase o Airway  Recovery position o Orientation o Paralysis/injury o Emotional support/ education Pharmacological Management of seizures  Anticonvulsants o Carbamazepine (8-12 mcg/mL) o Gabapentin o Phenytoin (10-20 mcg/ mL) o Valproate (50-125 mcg/mL) o Levetiracetam (12-46 mcg/mL)  Benzodiazepine o Lorazepam o Diazepam  Barbiturate o Phenobarbital  Surgical interventions  Supportive therapies/ general management Seizure complication  Status Epilepticus o Continuous seizure activity lasting more than 5 minutes o Frequent recurrent seizure without regaining consciousness in between them o Increased risk for permanent brain damage and death o Emergency AED- lorazepam (Ativan)  Generally same as all seizure management Epilepsy   Primary or secondary  Primary- idiopathic  Secondary- underlying causes  Men >women  Onset- early childhood or after age 65  Dementia id a leading cause of epilepsy among older adults  High fevers in childhood  subsequent epilepsy later in life o Esp w/ a family history of epilepsy  Same type of seizure each time  Symptoms will be similar to episode o Management/ assessment findings dependent on cause  Medical management medication o Often seizure-free w/a single anti-epileptic drug o May be able to discontinue seizure medication after several years o Medication and dosage can be complex  MD may need to adjust order  Compliance with therapy o Single drug at a relatively low dosage  Increase the dosage gradually until seizures are well controlled  Extensive education re: seizure medication management  Client teaching o Lifestyle changes  Risk factor reduction/ protection from injury  Falling  Drowning  Car accidents o Take medications exactly as prescribed  Before switching to a generic version of your medication or taking other prescription medications, over the counter drugs or herbal remedies to check with Primary Health care provider o never stop taking your medication without talking to your doctor  new or increased feelings of depression, suicidal thoughts are unusual changes in mood or behaviors Geriatric considerations  Medication management o Side effects, clearing/ metabolism  Patient education  Specialty care (neurology) Nursing diagnosis  Potential for injury related to uncontrolled movements of seizure activity  Potential for aspiration related to seizure activity   fear  knowledge deficit  potential for impaired social interaction related to chronic illness  potential service seemed service related to chronic illness Parkinson’s and other disorders Parkinson’s Disease  progressive disorder of the nervous system o affects movement  gradual o barely noticebale tremor  slowing/ freezing of movement o difficulty starting movement  middle or late life o risk increases with age o close relative= greater risk  men>women  insufficient dopamine o specific brain cells that produce dopamine die or become impaired o reason unknown  low norepinephrine levels o damage to the nerve endings that synthesize it o difficulty regulating the ANS  lewy bodies o unusual protein clumps found in the brain o significance unknown  clinical mamifestations o tremor  shaking begins in hand  most patients o bradykinesia  reduced ability to initiate voluntary movement  simple tasks difficult/timely  gait changes  difficulty initiating o hypokinesia  decreased muscle movement o dyskinesia  involuntary muscle movement o postural instability  stooping, leaning   poor balance o rigidity  muscle stiffness  mask/ stare  unblinking eyes  ROM/ pain o 1st sign- static arms o Uncontrolled sweating o Drooling o Pill tongue (tongue/ hands) o Dysphonia o Speech changes  Soft, rapid, monotoned  slurring, repeating o orthostatic hypotension o dementia (late) o depression/ anxiety o sleep problems  trouble falling asleep  frequent waking  sleep attacks during the day o difficulty chewing and swallowing  muscular o urinary problems  incontinence/ retention o Constipation o sexual dysfunction  desire  Diagnostic tests o No specific tests  R/O dx  Labs/ imaging not helpful o Medical history o Diagnosis largely based on s/s o Neurological exam  Walking and coordination  Simple hand tasks  Must have 2 of the following 4 o Tremor, rigidity, bradykinesia, and/or postural changes o PET scanning can be helpful if disease is progressed  Medical management- medications and interventions to improve tremors o Planning is important!!  o Anti-parkinson’s medications- levodopa  Dopamine agonist  Take with food o MAOI- phenelzine sulfate o Catechol O-methyltransferase (COMT) inhibitors- (tolcapone, entacapone) o Anticholinergics (benztropine, cogentin)  Dry mouth o Neural implant  Deep brain stimulation  Planning and interventions o Improving mobility  Appropriate activities, safety, improve balance o Enhancing self care activities  Independence in dressing o Improving bowel elimination o Improving nutrition  Aspiration precautions  Dysphagia diet  Avoid thin liquids o Enhancing swallowing o Encouraging use of assistive devices o Improving communication o Supporting coping o Promoting home based  Transitional care  Rehabilitation  Nursing focus o Medication regimen  Peak of medication action o Mobility  Activities to improve strength/ balance  Positioning/gait  Devices o Self-care o Bowel/ bladder control o Nutrition  Protein  Fats  Well balanced o Swallowing  Positioning during meals  Suction o Communication methods/ assistive devices  o Supporting coping o Promoting home-based transition/ rehab  Safety Bell Palsy  Patho- inflammation of the 7th cranial nerve  Assessment o Facial paralysis o Facial pain  Diagnosis o History and symptoms o Rule out stroke  Medical management o Corticosteroids (prednisone) o Analgesics for facial pain  Nursing management o Protect eye from injury o Facial massage  When pain has decreased o Avoid extreme temperature Trigeminal Neuralgia  Impingement of 5th intracranial nerve  “Tic Douloreux”  Assessment o Sharp sudden facial pain  Rapid start/ stop o Shooting/ burning o Facial twitching  Eye/ mouth  Diagnosis o Paroxysms  Trigger points o History  50s-60s  More common in females  MS  Exacerbations (stimulation) o Anything that causes the nerve to further impinge/ anything that leads to vasospasms  Washing face, shaving, brushing teeth, eating, drinking, cold air  Management o Medical management  Anticonvulsants (carbamazepine and gabapentin)   Carbamazepine (take with food, monitor therapeutic levels)  Phenytoin (second line)  Muscle relaxant (baclofen) o Surgical intervention (last resort)  Microvascular decompression  Radiofrequency  Percutaneous balloon micro-compression  Implant o Nursing management  Prevent pain  Temperature  Stimulation  Postoperative care  Neuro assessment  Monitor for chewing difficulty  Artificial tears Headache  Headache types o Primary o Secondary o Migraine  Migraine phases o Premonitory (hours prior)  Depression, irritability, cold, anorexia o Aura o Headache  Head pain, pressure, nausea/vomiting o Postdrome (recovery)  Fatigue, weakness, cognitive difficulty  Tension o Constant pain and pressure o Forehead, temple  Cluster o 1-8/ day, 15 min to 3 hrs o Eye, orbit  Diagnosis o History o Survey- location, duration, frequency o Environment o Medication and drug use o CT/ MRI  Medical management  o Nonpharmacological  Rest  Decrease stimuli  Dark/quiet  Cold compress  Elevate head  Prevention/ triggers (avoidance)  Menstruation  Vasodilation- alcohol  Diet o Anorexia o Tyramine (coffee, chocolate, cheese, dairy) o Caffeine  Therapy for headache o Pharmacological treatment  Oxygen therapy for cluster HA o Abortive therapy  Serotonin receptor agonist  Sumatriptan (20-60 minutes) o PO, nasal spray, sublingual o Vasoactive- do not use in pt with ischemic heart disease o Preventive therapy  Anticonvulsants  Divalproex sodium  Topiramate  Valproate  Beta blockers  Propranolol  Metoprolol  Nursing focus o Pain relief o Care @ home o Transitional care o Patient education Nursing diagnosis  Impaired physical mobility  Constipation  Imbalanced nutrition (less than body requirement)  Ineffective coping  Impaired verbal communication  Disturbed body image  Acute pain   Self-care deficit  Knowledge deficit Unit 6 Alteration in sensory perception- Auditory Hearing impairment disorders  Conductive Hearing Impairment o Cerumen Impaction o Foreign Body Occlusion o Otosclerosis  Sensorineural Hearing Impairment o Ototoxicity o Trauma o Meniere Disease  Acute Otitis Media  Chronic Otitis Media Conditions of the external ear  Impactions/ occlusions  external otitis o inflammation caused by bacteria or fungus  Staphylococcus or pseudomonas  Aspergillus o Pain/ tenderness, discharge, edema, erythema, pruritus, hearing loss, feelings of fullness in the ear o reduce discomfort , reduce edema, and treat the infection  foreign bodies Conditions of the middle ear  tympanic membrane perforation o trauma , infection o hearing loss, pain, vomiting, otorrhea  acute otitis media o frequent in children o pathogens- bacterial or viral o manifestations include otalgia (ear pain), fever, hearing loss, drainage  chronic otitis media o result of recurrent acute otitis media o chronic infection damages the tympanic membrane, ossicle, and involves the mastoid. Conditions of the inner ear   Disorders of the vestibular system affect more than 30 million of the United States o falls resulting from these disorders result in 100,000 hip fractures a year  dizziness o any altered sense of orientation in space  Vertigo o the illusion of motion or spinning sensation  Nystagmus o involuntary rhythmic movement of the eyes associated with vestibular dysfunction  Tinnitus o ringing in the ear hearing loss  inability to hear at normal volume  prevalence increases with age o 50% over age 75 o Presbycusis  exposure to excessive noise levels/ long term  types o conductive = temporary  external/middle ear o sensorineural = permanent  cochlea/ hair or vestibulocochlear nerve (inner ear) o mixed= both conductive and sensorineural o functional (psychogenic)  caused by emotional problem Manifestations of auditory damage/ injury  early symptoms o Tinnitus- perception of sound; often “ringing in the ears” o Decreased ability to hear in a group o Inability to hear normal volume  Impairment may be gradual o Not recognized by the individual  Gerontological o Cerumen hardens o Tympanic membrane scleroses o Cochlea degenerates  Increased hearing loss  deterioration of speech, fatigue, indifference, social isolation or withdrawal, and more. Management  Prevention (ear protection, decrease exposure, avoid trauma)   Related to cause  Early detection  Communication methods Guidelines for communicating with hearing impaired persons  Low tone, normal voice  Speak slowly and distinctly  Reduce background noise/ distractions  Face the person/ attention  Speak into the less impaired ear  Use gestures and facial expressions  Alternate communication (writing, interpreter) Conductive hearing impairment  Cerumen impaction o Assessment  Otalgia- ear pain  Hearing loss o Medical management  Irrigation  Pressure  Position  Suction  Instrument removal  Cerumenolytic agent  Glycerin, mineral oil, half strength H2O2 o Nursing management  Educating (cleaning)  Foreign body occlusion o Assessment  Pain  Decreased hearing o Medical management  Irrigation  Vegetables, insects  Suction  Instrument removal  Surgical removal  Deep, dangerous, difficult o Nursing management  Emotional support  Education  prevention  Otosclerosis o Assessment  Progressive hearing loss  Tinnitus o Diagnostics  Otoscopic exam  Rinne test- bone conduction longer than air conduction  Audiogram o Medical management  Hearing aid  Surgery  Prosthesis (stapedectomy/ stapedotomy) o Nursing management  Early identification  Fall prevention post op  Hearing improves soon after surgery Sensorineural hearing impairment  Ototoxicity o Assessment  Variable onset (per drug)  Tinnitus  Progressive o Recoverable? o Diagnostic testing  Audiogram o Medical management  Therapeutic/ toxic blood levels  Audiograms o Nursing management  Identify alternate drug therapy  Ongoing assessments/ monitoring  Status/ progression  Blood levels  Trauma- tympanic membrane perforation o Assessment  Hearing loss  Pain  Otorrhea/ Rhinorrhea- CSF  Vomiting o Diagnostics  Otoscopic exam o Medical management  Surgical intervention   Tympanoplasty   Trauma- head injury or temporal bone fracture o Check for otorrhea- drainage from ear o Check for rhinorrhea- drainage from nose o Clear, watery drainage may be CSF  Meniere Disease o Abnormal inner ear fluid balance  Malabsorption of the endolymphatic sac or blockage of the endolymphatic duct o Manifestations- triad of symptoms  TRIAD- episodic vertigo, tinnitus, & fluctuating sensorineural hearing loss  Feeling of pressure  Nausea and vomiting o Diagnostics (audiogram)- sensorineural hearing loss o Treatment  Low sodium diet (1,000-1,500 mg/day)  Meclizine (Antivert)  Benzodiazepine (diazepam, valium)  Antiemetics (promethazine, Phenergan)  Diuretics (HCTZ, K sparing triamterene or spironolactone)  Surgical management  Endolymphatic sac decompressions/ vestibular nerve sectioning o Nursing care  Education  Diet- chart 64-8, p. 1933  Falls  Medication management Acute Otitis Media  Assessment o Otalgia o Drainage  o Fever o Severity  Medical management o Oral ABX per MD preference o Drops o Pain  Surgery o Myringotomy/ tympanotomy  Nursing management o Post op o Pain relief o Injury prevention Chronic otitis media  Assessment o Minimal symptoms o Hearing loss o Persistent/ intermittent, foul smelling otorrhea o Postauricular tenderness o Erythema/ edema o Chronic mastoiditis o Cholesteatoma- cysts-like lesion inner ear  Medical management o Suction o Antibiotic- drops/ powder/ systemic  Surgery o Tympanoplasty o Ossiculoplasty o Mastoidectomy Surgical procedures of the ear/ mastoid  Assessment o Health history  Include data related to the ear disorder, hearing loss, otalgia, otorrhea, and vertigo o Duration and intensity, causes, and previous treatments o Medications o Physical assessment  Erythema, edema, lesions  Discharge: color and odor  Review prior test results  Planning o Major goals include  Reduction of anxiety   Freedom from pain and discomfort  Prevention of infection  Stable or improved hearing and communication  Absence of vertigo and injury  Increased knowledge of disease, surgical procedure and postop care  Interventions o Anxiety  Reinforce information and patient education  Provide support and opportunity for discussion o Pain  Generally, low pain  Medicate with analgesics for ear discomfort  Note: Occasional sharp, shooting pains may occur  eustachian tube opens and allows air into the middle ear  constant throbbing pain and fever may indicate infection o injury/ safety  Safety measures  assisting with ambulation  Provide antiemetics or antivertigo medications (antihistamine)  Report facial nerve changes  Interventions-surgical o Safety  Activity restriction  Vertigo  Potential complications o Communication/ hearing  Hearing may reduce for several weeks after surgery because of edema, accumulation of blood and fluid in the middle ear, and dressings and packings  Use measures to improve hearing and communication as discussed in “Communicating with Hearing Impaired Persons.” o Preventing infection  Hearing may reduce for several weeks after surgery because of edema, accumulation of blood and fluid in the middle ear, and dressings and packings  Use measures to improve hearing and communication as discussed in “Communicating with Hearing Impaired Persons.”  Diagnoses o Hearing loss o Risk for injury r/t alterations in sensory perception o Impaired verbal communication r/t inability to hear voice o Social isolation r/t difficult with communication o Hearing loss r/t altered transmission of sound  o Acute pain r/t impaction o Risk for infection r/t eardrum perforation o Acute pain r/t trauma o Risk for injury r/t vertigo o Impaired physical mobility r/t dizziness o Acute pain r/t inflammation Visual Impairment Disorders  Impaired Vision o Refractive Errors o Visual Impairment and Blindness  Age-Related Disorders o Cataracts  Retinal Disorders o Retinal Detachment o Diabetic Retinopathy o Macular Degeneration  Glaucoma o Wide-Angle Glaucoma o Narrow Angle- Glaucoma  Conjunctivitis Impaired Vision  Refractive errors o corrected by lenses that focus light rays on the retina  Emmetropia: normal vision  Myopia: nearsighted (blurred distance vision)  Hyperopia: farsighted (blurred near vision)  Astigmatism: distortion caused by irregularity of the cornea  Age related change: presbyopia  Management: corrective lenses / Lasik Eye shape determines visual acuity in refractive errors Low vision and Blindness  Low vision  o Visual impairment that requires devices and strategies in addition to corrective lenses o Best corrected visual acuity (BCVA) of 20/70 to 20/200  Blindness o BCVA 20/400 to no light perception o “legal blindness” is BCVA that does not exceed 20/200 in better eye or widest field of vision is 20 degrees or less  Impaired vision often accompanied by functional impairment Visual assessments  Patient interview  Visual acuity  Vidual fields  Color perception Management  Vision aids  Support coping strategies, grief processes, and acceptance of visual loss  Strategies of adaptation to the environment o Placement of items in room o Sighted guide o “clock method”  Communication strategies o Braille, audio  Collaboration with low vision specialist, occupational therapists, or other resources  Community resources (social services)  Home based care resources (social services) o Guide dog, cane, vision rehab Ophthalmic medication  Limited absorptive ability  Barriers include o Size of the conjunctival sac o Corneal membrane barriers o Blood-ocular barriers o Tearing, blinking, and drainage  Intraocular injection or systemic medication may be needed to treat some eye structures or to provide high concentrations of medication  Topical medications (drops and ointments) o Less invasive, fewer side effects, self- administration  Topical anesthetics o Proparacaine HCL, tetracaine HCL  Mydriatic and cycloplegic agents (dilation)  o Contraindicated with narrow angles or shallow anterior chambers and in patients on monoamine oxidase inhibitors or tricyclic antidepressant o May cause CNS symptoms and increased BP, especially in children or older adults o Phenylephrine (synephrine), Atropine, Scopolamine  Glaucoma o Increase aqueous outflow or decrease aqueous production o May constrict the pupil and may affect ability to focus the lens of the eye o Affects vision  blurred vision o May also may produce systemic effects o Hyperosmotic (acetazolamide) o Ocular hypotensive (pilocarpine) o Beta blockers (betaxolol)  Anti-infective o Penicillin (amoxicillin) o Cephalosporin (cephalexin) o Aminoglycosides (gentamycin) o Fluoroquinolones (levofloxacin) o Antiviral (acyclovir)  steroid/ NSAIDs o inflammatory conditions o Side effects of long-term topical steroids include glaucoma, cataracts, and increased risk of infection o Oral NSAID therapy may be used as an alternate to steroid use  anti-allergy o hypersensitivity to environment allergens  irrigant/ lubricant o artificial tears, cleanse external lids Instilling eye medication  Hand hygiene / adequate lighting  Verify medication  Comfortable position  Avoid touching the tip of the medication container to any part of the eye or face  Hold the lower lid down; do not press on the eyeball. Apply gentle pressure to the cheekbone to anchor the finger holding the lid.  Instill eye drops before applying ointments  Keep the eyelids closed and apply gentle pressure on the inner canthus (punctal occlusion) near the bridge of the nose for 1 or 2 minutes immediately after instilling eye drops.  Use a clean tissue to gently pat skin to absorb excess eye drops that run onto the cheeks.  Apply a 0.25–0.5-inch ribbon of ointment to the lower conjunctival sac.  Wait 5 minutes before instilling another eye drop and 10 minutes before instilling another ointment. Age related disorders  Cataracts o Opacity or cloudiness o Increased incidence with aging; 50% by age 80 o Leading cause of blindness in the world o Risk factor- age o Three types  Traumatic  Congenital  Senile cataract o Clinical manifestations  Painless  Blurry vision  Dimming  Diplopia (double vision)  Haziness  Decrease in color perception  Sensitivity to glare  Reduced visual acuity  Myopic shift  Astigmatism  Opthalmascope, slit lamp, or inspection  Snellen chart, ophthalmoscopy  Slit lamp exam o Prevention  Weight reduction  Smoking cessation  Blood sugar control  Sunglasses o Medical and surgical management  Medical  Medication (alpha antagonists, adrenergic blocker- tamsulosin)  Eyeglasses  Surgical  Surgery needed when vision affects activity  Outpatient basis/ local anesthesia o Phacoemulsification o Lens replacement  Surgery usually takes less than 1 hour, and patients are discharged soon afterward  Complications are rare but may be significant   Pre op/ post op care  Discharge teaching o Normal- morning discharge, redness, itching, scratchy feeling o Abnormal- new floaters (dots), flashing lights, decreased vision, pain Retinal Disorders  Retinal detachment o Rhegmatogenous detachment, most common o Manifestations  Unilateral shade/ curtain  Bright flashing lights  Sudden onset of floaters o Diagnostic assessment  Assessment of retina by indirect ophthalmoscope  Ultrasound  Dilated fundus o Surgical treatment  Scleral buckle- compresses sclera  Vitrectomy-  Intraocular procedure  Gas bubble, silicone oil, perfluorocarbon and liquids may be injected into vitreous cavity  Post op positioning / education – prone o Nursing management  Patient education  Eye surgery is most often done as an outpatient procedure o Patient education is vital  Signs and symptoms of complications o increased IOP o infection  promote comfort  post op positioning  prone position  Retinal vascular disorders o Diabetic retinopathy o Assessment  Cataracts  Blurred vision  Floaters  Sudden vision changes  Up to complete loss  o Diagnostics  Retinal visualization  Eye exam  Fluorescein  Angiography o Management  Primary/secondary  Glucose control  Laser treatment  Nursing management  Patient education  Assist with vision loss/ self-care Age-related macular degeneration  54% of all blindness in older adults  S/S o Gradual blurring o Straight lines appear wavy / curved  Diagnostics o Optical tomography o Ultrasound  Types o Dry or nonexudative type; most common, 85% to 90%  Slow onset  Layers of the retina break down with the appearance of drusen (yellow deposits)  Wet type o May have abrupt onset o Proliferation of abnormal blood vessels growing under the retina  Photodynamic therapy for slowing progression of AMD o No treatment o Vasoproliferation for wet  Light sensitive verteporfin dye is injected into vessels  Laser activates the dye, shutting down the vessels without damaging the retina  Slow or stabilize vision loss   Avoid exposure to sunlight or bright light x 5 days after treatment (re- activation of dye in vessels near the surface of the skin)  Nursing management o Patient education  Amsler grid o Supportive care o Promote safety o Recommendations  Improve lighting  Magnification devices  Referral to vision center Glaucoma  Congested aqueous humor  increased IOP  damage to optic nerve  Incidence increases with age  Risk factors: Chart 63-5 o African American o Cardiovascular disease o Diabetes o Family history of glaucoma o Migraine syndromes o Nearsightedness (myopia) o Older age previous eye trauma o Prolonged use of topical or systemic corticosteroids o Thin cornea  General manifestations o Blurred vision o Halos o Difficulty focusing o Loss of peripheral vision o Poor vision in low light o “Silent thief”  Conditional unawareness until significant vision loss o Headache  Aching / dull discomfort around eyes o Diagnostics:  Tonometry  Ophthalmoscopy  Visual field assessment  Types of glaucoma o Open Angle / Wide Angle  90%  Painless / low pain   Progressive  Optic nerve damage / field deficit o Closed Angle / Narrow Angle  Medical Emergency!  Intense pain  Nausea / vomiting  Hazy / blurred vision  Rainbow circles around lights  Sudden onset  Loss of vision  Treatment o Goal: prevent further optic nerve damage, prevent blindness o Maintain IOP within a range unlikely to cause damage o Pharmacologic therapy:  Hyperosmotic (acetazolamide)  Ocular hypotensive / cholinergic agonist (improve fluid flow - pilocarpine)  Beta blockers (reduce production- “olol”)  Miotics -dilate  Alpha2-agonists (reduce production – “ondine”)  Carbonic anhydrase inhibitors (reduce production – “zolamide”)  Prostaglandins (improve fluid alternate route – “prost”) o Surgery  Trabeculectomy  Small hole, flap “door”  Drainage shunts  Small insert, drains  Nursing management o Assess for knowledge level and adherence to treatment  Multiple per day  Correct usage  Therapeutic regimen / chronic condition o Provide education regarding use and effects of medications o Medications used for glaucoma may cause vision alterations and other side effects  Compliance o Provide support and interventions to aid the patient in adjusting to vision loss or potential vision loss  Home safety  Self care  Nursing management for the glaucoma surgery patient o Preoperative care  Standard care for ambulatory surgery  Dilating eye drops or other medications as ordered  o Postoperative care  Patient education  Provide written and verbal instructions  Instruct patient to call physician immediately if:  vision changes  continuous flashing lights  redness, swelling, or pain increases  type and amount of drainage increases  significant pain is not relieved by acetaminophen Conjunctivitis  Pink eye o Cause:  Bacterial, viral, fungal, parasitic, allergic, toxic o Viral = contagious o Redness o Burning o Discharge  Purulent  Morning  Difficulty opening o Diagnosis via physical exam  Medical management o Topical antibiotics  Drops  Ointments  Nursing management o Education  Medication administration  Cleaning  Transmission prevention- hand washing Diagnoses  Fear r/t loss of sight  Social isolation r/t inability to see  Vision loss r/t impaired visual function  Self care deficit r/t inability to see to perform ADLs  Vision loss r/t impaired sensory input  Anxiety r/t vision change  Vision loss r/t visual impairment  Impaired home maintenance r/t post op care  Risk for injury r/t deteriorating vision  Hopelessness r/t deteriorating vision   Self neglect r/t change in vision  Social isolation  Risk for injury  Acute pain r/t inflammation Musculoskeletal Injuries of the musculoskeletal system  Break / fracture: disrupted integrity of bone  Contusion: soft tissue injury produced by blunt force  Strain: Pulled muscle injury to the musculotendinous unit  Sprain: injury to ligaments and supporting muscle fiber around a joint  Dislocation: articular surfaces of the joint are not in contact o Traumatic dislocation  Emergency with pain change in contour, axis, and length of the limb and loss of mobility Soft Tissues Injuries- sprains/ strains  Patho  Strain o Overuse, overstretch, excessive stress o Muscle / tendon  Sprain: o Ligaments / tendons surrounding a joint o Twisting / hyperextension  Assessment o Pain o Swelling o Discoloration  Diagnosis o Physical assessment o Imaging to r/o fracture  Interventions o PRICE o P  Splint / support o R o I  Aka: cryotherapy  24-72 h, 20 min  o C  Perfusion o E  At or above heart o Frequent assessment  Q15 min x 1-2 hours o Medications  Analgesics / anti-inflammatories o Education  Healing  Restrictions  Skin management / infection  Ligament damage= sprain o Assessment  “Pop” in joint  Swelling  Pain with weight bearing  Joint instability o Diagnosis  Physical assessment  Imaging to r/o fracture o Medical management  Consider severity  Brace / crutches  PT – strengthen supportive muscles  Surgical Intervention  Medication  Analgesics o Nursing management  PRICE  Education (devices / limitations)  Pain management  S/S complications  Neurovascular  Infection  Skin breakdown  VTE - venous thromboembolism Soft tissue injuries- joints & tendons & muscles  Synarthrosis (fibrous joints) - immovable  Amphiarthrosis (cartilaginous joints)- limited  Diarthrosis (synovial) - movable  Skeletal Muscle Contraction  o Isometric – length of muscle remains constant, force generated is increased (pushing against immovable object) o Isotonic – shortening of muscle w/o increase in tension w/i muscle (flexing forearm)  Muscle Tone o Spastic – muscle with greater than normal tone o Atonic – denervated muscle, soft & flabby, atrophies  Muscle Use and Disuse o Hypertrophy – increase in size of individual muscles fibers (exercise, weightlifting) o Atrophy – decrease in size of muscle fibers, disuse (bedrest, immobility) Gerontology  Pain / joint limitations  Loss of height o osteoporosis, kyphosis  Thinning intervertebral discs  Compressed vertebral bodies / flexion of knees / hips  Change in normal strength Back pain  Patho  Rod w/ inflexible vertebrae / flexible intervertebral discs  Protects spinal cord  Spinal curves absorb stress o Core strength  Dense / irregularly shaped fibrocartilage o Disc degeneration  back pain  Acute: Up to 12 weeks o Self limiting, 4-6 weeks  Chronic: 3 months +  Disc degeneration o L4-S1 highest incidence of mechanical stress / degeneration  Disc protrusion o Pressure on nerve  Prevention! (p 1162, chart 41-2) o Weight loss o High heels o Daily walks (distance, pace) o Jumping / jarring o Posture o Flexibility o Push, don’t pull  o Avoid twisting o Lifting mechanics – close to body o Change positions often, avoid prolonged standing o Complimentary muscles o Lumbar support  Assessment o Acute / chronic pain o Fatigue o Radiculopathy o Sciatica o Mobility / gait o Sensory o Strength  Diagnosis o History / physical exam  Focused o Imaging  X-ray, CT, MRI  Bone Scan  Myelogram  Ultrasound  EMG o Blood studies  Medication management o Analgesics  No Tylenol / corticosteroids o Muscle relaxant  cyclobenzaprine / Flexeril o Anti anxiety o Tricyclic antidepressant  amitriptyline / Elavil o SNRI  duloxetine o Anticonvulsant  gabapentin / Neurontin  nonpharmacologic management o Rest o Modify activity o Improve mobility  No bed rest  20-50 min  Exercise!  Yoga  o Heat / cold o Chiropractic / PT o Support belt*** o Cognitive Behavioral Therapy o Education o Weight / body mechanics o Avoid strain o Document pain / response to tx  Nursing goals/ interventions o Relieve pain o Improve physical mobility  Adherence to exercise program o Control risk factors  Weight o Improved body mechanics  Lifting limits  Muscle groups o “How to get up” (OOB) o Assess tolerance / use of medications o Encourage PT / independence Fractures  Closed  Open o Type 1 (clean, 40) o Lifestyle (smoking, poor diet) o Comorbidities (malignancy, osteoporosis, diabetes) o Medications (steroids) Complications of wound healing of fractures  Hypovolemic shock  Vascular injury  Infection o Osteonecrosis o Osteomyelitis  Compartment syndrome  o Neurovascular damage  Perfusion / neurovascular compromise  Paresthesia – 1st sign  Pain (deep, throbbing, unrelenting, disproportionate)  Paralysis  Pallor  Pulseless o Mgmt  Decrease pressure  Emboli (fat/ PE/ DVT) o Fat embolism syndrome  Trauma / Long bones (12-72 hours)  Triad (hypoxemia, neuro compromise, petechial rash)  Hypoxia, tachypnea, dyspnea, tachycardia, chest pain, low-grade fever, crackles, resp failure  Chest X-ray shows ARDS or normal  No treatment – supportive therapy Dislocation/ subluxation  Pathology o Articular misalignment  Assessment o Acute pain o Position / awkward o Decreased ROM  Diagnosis o Bilateral assessment o X-ray  Medical management o Immobilization before movement o Reduction o Medications  analgesia  muscle relaxant  possible anesthesia  nursing interventions o Neurovascular assessment o Documentation of communication o Education on exercise / activity o Education r/t complications  Pain  edema  compartment syndrome Bone structure disorder- Scoliosis  assessment o Abnormal lateral curving o Unlevel shoulders o Asymmetric waistline o Prominent scapula o Loss of height  Diagnosis o Physical exam Bone infection- Osteomyelitis  Inflammation  Necrosis  Reformation w/ new bone  Hematogenous- o Due to bloodborne spread of infection  Contiguous focus o Contamination from surgery, open fracture, traumatic injury  Vascular insufficiency o Diabetics, PVD, usually affects the feet  High risk o Diabetes o Older adults o Poor nutrition o Obesity o Rheumatoid arthritis o IV drugs  Assessment o Chills o High fever  o Tachycardia o General malaise o Pain o Swelling o Tenderness o Sepsis (sudden & systemic)  Diagnosis o X-ray – soft tissue edema o MRI o ESR - Erythrocyte Sedimentation Rate o WBC o Cultures may be unreliable  Bone bx*  Prevention o No elective sx w/ infection o Abx- before and after surgery  Medical management o Pharmacology  Long term antibiotics (3-6 wks) o Surgery  Debridement  Sequestrectomy  Wound VAC o Nursing management  Relieve pain  Improve mobility  Control infection Metabolic- bone disease- Osteoporosis  Gerontology o Altered calcium absorption o Post menopausal women, older men o Environmental hazard o Diminished senses o Cardiovascular response / medication response  Assessment o Signs / symptoms  Low back  Spontaneous fracture  Shortening  Diagnosis o X-ray o DEXA scan   Dual Energy X-ray Absorptiometry  Interventions o Education (disease, therapy) o Weight bearing exercises o Balance exercises o Daily walks, stationary bicycle, rowing machines o Calcium / vit D (dairy, sardines with bones, salmon, green leafy vegetables) o Limit alcohol, caffeine & soft drinks o Safety and fall precautions  Remove household hazards  Good lighting and vision  Using bars in bathtub  Well fitting shoes  Fracture management o Manage pain o Conservative therapy o Surgical intervention  Medical Management o Avoid sedation o Bisphosphonates (ibandronic acid / Boniva, alendronate / Fosamax, Ibandronate) o -No food / drug (water only) o -Positioning o Estrogen (Roloxifene) o RANKL Inhibitor (denosumab/Prolia) o SubQ q6 months o Decreases bone resorption o Calcitonin o Vitamin D o Calcium Metabolic Bone Disease- Paget disease u Assessment u Pathologic fx u Bowing of legs u Arthritis u Back and joint pain u Skeletal deformity (old fracture sites) u Sclerotic changes u Cortical thickening of long bones u Diagnosis u X-ray u Elevated ALP – alkaline phosphatase  u Bone scan (progression) u Gerontology u Education re: compensation for altered musculoskeletal function (risk for falls) u Assess home environment (safety) u Coping w/ health problems u Management u Walking aids / shoe lifts u PT u Weight control (decrease bone / joint stress) u Promote understanding (osteoporosis, treatment) u Relieving pain u Preventing injury u Pharmacology u Bisphosphonates* u Alendronate therapy u Antiosteoclastic therapy u Cytotoxic abx - (Plicamycin) Osteomalacia  Patho o A metabolic bone disease characterized by inadequate bone mineralization  Assessment o Softening and weakening of the long bones o Bowing / pathologic fractures o Deformities  Kyphosis o Pain / tenderness  To touch  Diagnosis o X-ray – bone demineralization  Compression fx vertebrae o Blood work  ALP elevated  Calcium decreased  Phosphorus decreased o Bone biopsy  Care & Treatment o Physical, psychological, and pharmaceutical measures to reduce discomfort and pain o Correct underlying cause o Kidney disease  Supplement: calcitriol o Malabsorption   Supplemental vitamin D and calcium o Exposure to sunlight  ultraviolet radiation transforms a cholesterol substance (7- dehydrocholesterol) present in the skin into vitamin D o Dietary  Calcium & Vitamin D – milk, cheese Bone cancer- Tumors  Assessment o Asymptomatic o Pain o Disability (variable) o Weight loss o Malaise o Fever o Pathologic fractures  Diagnosis o H&P o CT o Bone scan o Myelography o Arteriography o MRI o Biopsy o Chest X-ray – lung mets  Medical management o Surgery/ removal  Nursing interventions o Assess patient/ family coping o Wound care o Pain management o Pre-op and post-op care Disease of skeletal muscle- muscular dystrophy  Assessment o Muscle wasting o Weakness o Dysphagia o Mental deficits o Vision o Infertility  Diagnosis o Physical examination  o Muscle biopsies o Genetic testi  Medical management o Supportive care (activity, independence, ROM) o Prevention of complications  Respiratory & skin o Splinting  Nursing interventions o Maintain and support function  Activity  Bowel / bladder o Age-appropriate care and considerations Osteoarthritis  Assessment o Pain o Stiffnes o Functional impairment  Diagnosis o Blood testing o Joint fluid o X-ray – narrowing of joint space, o osteophytes  Medical management o Pharm:  Acetaminophen – 1000mg/6 hrs  NSAIDs  Analgesics (topical)  COX2 enzyme blockers (Celebrex)  Caution - Cardiovascular disease  Opioids  Intra-articular corticosteroids  Glucosamine / chondroitin (shellfish / asthma) o Surgical Management  Arthroplasty – total joint replacement  Nursing management o Education o Diet (calcium, vit D)  Avoid alcohol o Fracture / injury prevention o Promote understanding o Relieve pain / stiffness  Progressive exercise, weight bearing   Warm > cold o Optimize functional ability  Devices o Improve bowel elimination o Weight loss Secondary Joint Dysfunction- Psoriatic Arthritis  Assessment o Inflammatory back pain o Worse at night o Infection  Diagnosis o Inflammatory markers  Medical managmwnt o Maintain mobility o Pain management o Pharmacologic  Analgesics  Immunosuppression (methotrexate, leflunomide, sulfasalazine)  Corticosteroids - periodic, not long-term  TNF Alpha Inhibitor (etanercept / Enbrel, infliximab, adalimumab/Humira)  Suppress immunity, Adjunct to MTX  Nursing interventions o Activity limitations o Address psychological state o Manage symptoms Secondary joint dysfunction- Gout  Assessment o Asymptomatic o Increased uric acid levels o Recurrent severe articular / periarticular inflammation  Diagnosis o Increased serum uric acid level o Symptoms  Severe pain at night  Redness  Swelling  warmth  medications o Analgesia  indomethacin / Aleve o Anti-inflammatory   Colchicine  Decreases uric acid production  Maintenance AND treatment  Corticosteroids o Xanthan oxidase inhibitors  Interrupt breakdown of purines  Allopurinol, febuxostat  Nursing o Restrict foods high in purines (organ meats) o Limit alcohol consumption o Maintain healthy weight o Pain management / rest periods o Adequate fluid Secondary joint dysfunction- carpal tunnel syndrome  Clinical Manifestations (one or both hands) o Numbness or tingling o Night pain o Fist clenching on awakening o Pain extending to the elbow, wrist or hand o Problems with fine finger movements (coordination) o Weak grip (difficulty carrying bags)  Risk Factors: o Overuse / strain / repetitive forceful / awkward movement of wrists and hands  Assembly line / computer work  Use of power tools  Teaching o Hot and/or cold compresses o Reduce/avoid repetitive movements o Exercise hands in warm water o Personal care / assistance & support  Diagnostics o Phalen’s Test o Tinel’s Test “taps”  Medical management o Wrist immobilizer o NSAIDs / analgesia o Corticosteroid injections o Acupuncture o Surgery  Nursing management post op o Neurovascular assessment o ROM (finger)  o Swelling / infection  Teaching post op o NSAIDs w/ food o Splints when working w/ hands o Splints at night (per MD) o Education – may not be curative o Elevation for swelling o Report increased pain  Surgical management o Releases compressed median nerve o Rapid recovery o Complication: nerve damage Amputation  Necessary if: o Poor circulation o Necrosis o Infection / gangrene  Elective v. traumatic o Elective r/t perfusion o Traumatic r/t injury  Diagnosis o Physical exam o Diagnostic studies  Medical management o Rigid dressing (remove to assess, replace to control edema) o Rehabilitation  Highest level of function & activity  Independence  Prosthetics  Support groups  Nursing interventions o Pain control  Sandbag for muscle spasms o Wound healing / assessment o Enhancing body image o Grieving o Positioning Post Op  Elevation v. proning  Complications o Hemorrhage o Hypoperfusion o Phantom pain  o Infection o Neuroma o Flexion contracture  Psychosocial considerations o Loss o Grieving o Lifestyle Nursing diagnoses  Anxiety r/t back injury  Ineffective coping  Impaired physical mobility r/t pain  Chronic or acute pain r/t injury or inflammation or edema  Risk for constipation r/t decreased activity or side effect of pain medication  Deficient diversional activity r/t immobility  Risk for peripheral neurovascular dysfunction r/t treatment of fracture  Self care deficit r/t inability to use a joint  Risk for injury  Risk for infection: bone abscess formation  Activity intolerance  Disturbed body image  Decisional conflict r/t treatment choices  Deficient knowledge r/t treatment regimen  Ineffective airway clearance r/t muscle wasting  Self care deficit r/t feeding, bathing, dressing  Impaired transfer ability  Impaired skin integrity r/t surgical amputation  Grieving or risk for complicated grieving r/t loss of body part and resulting disability Unit 5 Review  Acute disorders of the brain o TIA/RND o Ischemic stroke o Hemorrhagic stroke  Chronic disorders of neurolgic function o Brain disorders  Seizure disorder  Epilepsy  Parkinson disease o Bel palsy o Trigeminal neuralgia o Headache  TIA/RIND o Transient ischemic attack/reversible ischemic neurological deficit  Symptoms last 1-2 hours  Sudden loss of motor, sensory, visual function  Symptoms such as ataxia, aphasia, hemianopsia  May be warning sign of impending ischemic stroje  No permanent ischemia  Initial diagnostic test= non contrast CT scan  Ischemic stroke o Disruption of cerebral blood flow due to obstruction od blood vessel  Thrombi or emboli o Hemiplegia/hemiparesis, confusion, agnosia, aphasia, hemianopsia, ataxia, sudden severe headache o Initial diagnostic test= non contrast CT scan o Treatment= thrombolytic therapy= tissue plasminogen activator (tPA)  Window of 3 hours from symptom onset  May be extended to 4.5 hours in some situation  Determine when last seen normal o Prevention- smoking cessation, physical activity, reduce alcohol consumption, healthy weight  Hemorrhagic stroke o Caused by bleeding into brain tissue, ventricles, or subarachnoid space  Spontaneous rupture of small vessels  Ruptured intracranial aneurysm  Ruptured AVM o Most common with HTN, cerebral atherosclerosis o Symptoms similar to ischemic stroke plus sudden severe headache, N &V, change in LOC, seizures o Complications - increased ICP  Sudden, new headache, pupillary changes  Quiet, non-stimulating environment o Medical management  Bedrest with sedation  If caused by anticoagulation with Warfarin – FFP, Vitamin K  Surgical management  Right Hemispheric Stroke vs Left Hemispheric Stroke o Right  Paralysis or weakness on left side of body  Left visual field deficit  Spatial-perceptual deficits  Increased distractibility  Impulsive behavior and poor judgement  Lack of awareness of deficits  o Left  Paralysis or weakness on right side of body  Right visual field deficit  Aphasia (expressive, receptive, global)  Altered intellectual ability  Slow cautious behavior  Nursing care following stroke o Aphasia  Face pt, establish eye contact  Speak in clear, unhurried manner, normal tone of voice  Limit conversation to practical, concrete matters  Use gestures, pictures, objects, writing  State what items are as pt. handles them  Be consistent with words, gestures  Reduce background noise o Hemianopsia  Place objects within field of vision  Approach from side of intact field of vision  Instruct/remind pt to turn head in direction of visual loss  Encourage use of eyeglasses if available  Educate within intact visual field  Place objects in center of intact visual field  Encourage use of a cane to identify objects in periphery  Consistently place items in the same location  Explain the location of objects when placing them near patient  Seizure o Electrical disturbance in nerve cells in one section of the brain o Classifications - Focal, Generalized, Unknown o During a seizure  Provide privacy  Ease pt to floor if possible  Protect head with pad to prevent injury  Loosen constrictive clothing  Push aside furniture  If in bed, remove pillows, raise side rails  Place on side, turn head to side  Do not pry open jaws or restrain o After a seizure  Keep pt on one side  Make sure airway is patent  Reorient pt when they awaken  Stay a distance away if agitated but close enough to prevent injury until fully awake  Status Epilepticus o Acute prolonged seizure activity o Series of generalized seizures that occur without full recovery of consciousness between attacks o May lead to irreversible and fatal brain damage o Airway and adequate oxygenation established o Initially - IV diazepam, lorazepam, or fosphenytoin o Later - phenytoin, phenobarbital o Monitor respiratory and cardiac function  Parkinson Disease o Slowly progressing neurologic movement disorder o Eventually leads to disability o Idiopathic but likely combination of age, environment, heredity o Decreased levels of dopamine o Clinical manifestations:  Tremor  Rigidity  Bradykinesia  Postural instability  Orthostatic hypotension o Medical management -dysphagia diet, aspiration precautions o Surgical management – deep brain stimulator o Education - schedule activity when medication peaks  Bell Palsy o Facial paralysis caused by unilateral inflammation of 7th cranial nerve o Weakness/paralysis of facial muscles o Decreased lacrimation o Facial pain o Medical management  Corticosteroid therapy  Analgesic agents o Nursing management  Protecting eye from injury  Messaging the face to maintain muscle tone  Trigeminal Neuralgia o Condition of 5th cranial nerve o Sudden facial pain o Caused by stimulation of affected nerve branches  Washing the face  Shaving  Brushing the teeth  Eating  Drinking   Cold air o Medical management  Pharmacologic – carbamazepine  Surgery – high rate of recurrence and complications  Headache o Migraine, tension, cluster o Migraine – complex of symptoms characterized by headaches lasting from hours to days  With or without aura  H&P to assess factors the precipitate or provoke it  May be provoked by medication – antihypertensive, diuretic, anti- inflammatory, MAO inhibitors  May be provoked by stress  Prevention = avoid triggers  Alcohol causes vasodilation  Nitrites, vasodilators, histamines Unit 6 Alterations in sensory perceptions Hearing Impairment Disorders o Conductive Hearing Impairment o Cerumen Impaction o Otosclerosis o Sensorineural Hearing Impairment o Ototoxicity o Trauma o Meniere Disease o Acute Otitis Media o Chronic Otitis Media  Cerumen Impaction  o Condition of external ear o May cause otalgia (sensation of fullness or pain in the ear) o Removed with irrigation, suction, instrumentation  Gentle irrigation with warm water  Warm glycerin, mineral oil, half-strength hydrogen peroxide can be used to soften cerumen  Otosclerosis o Condition of middle ear o Involves the stapes – cannot vibrate o Results from formation of spongy bone around stapes bone o Medical management: hearing aids o Surgical management: stapedectomy  Removal of diseased stapes and replacement with prosthesis  Hearing loss generally improves following surgery  Ototoxicity o Condition of inner ear o Hearing loss caused by medications: ASA, quinine, aminoglycosides, antineoplastic agents, loop diuretics o Usually causes permanent hearing loss o Patients should be counseled about side effects o Medical management: close monitoring of blood levels of medications, audiogram o Nursing management: review record to identify ototoxic medications  Trauma- Tympanic membrane perforation o Condition of middle ear o Usually caused by infection or trauma  Skull fracture  Injury from explosion  Severe blow to the ear  Foreign objects – cotton-tipped applicators, hairpins o Medical management:  Assess for clear, watery drainage from ear or nose  Cerebrospinal fluid  Meniere Disease o Condition of the inner ear o Abnormality of inner ear fluid balance o Caused by malabsorption in endolymphatic sac or blockage in the endolymphatic duct o Clinical manifestations:  Episodic vertigo  Tinnitus  Fluctuating sensorineural hearing loss o Medical management: low sodium diet  o Pharmacologic therapy: antihistamines, tranquilizers (diazepam), antiemetic agents, diuretics  Acute Otitis media o Acute infection of the middle ear o Most commonly seen in children o Lasts less than 6 weeks o Pathogens usually bacterial or viral o Clinical manifestations: otalgia, otorrhea, fever, hearing loss o Medical management: antibiotics o Surgical management: myringotomy/tympanotomy with tubes  Chronic otitis media o Caused by recurrent acute otitis media o Chronic infections damage tympanic membrane, destroy ossicles, involve mastoid bone o Medical management: suctioning, antibiotics o Surgical management:  Tympanoplasty  Reconstruction of tympanic membrane  Ossiculoplasty  Reconstruction of middle ear bones  Mastoidectomy  Removal of cholesteatoma  Risk of damage to facial nerve Visual Impairment Disorders o Age-Related Disorders o Cataracts o Retinal Disorders o Retinal Detachment o Diabetic Retinopathy o Macular Degeneration o Glaucoma o Wide-Angle Glaucoma o Conjunctivitis  Cataracts o Lens opacity or cloudiness o A leading cause of blindness in the world o One or both eyes at any age but usually older adults o Clinical manifestations:  Double vision  Haziness  Decreased color perception  o Surgical management:  Phacoemulsification  Lens replacement  Risk for retinal detachment following surgery  Report new floaters, flashing lights, decrease in vision, pain  Retinal detachment o Clinical manifestations:  Sensation of shade or curtain coming across vision of one eye  Cobwebs  Bright lights  Sudden onset of great number of floaters o Surgical management:  Scleral buckle  Vitrectomy  Prone position following surgery  Diabetic Retinopathy o Serious complication of diabetes o Proliferation of blood vessels in back of eye o Caused by uncontrolled blood glucose, HTN o Annual eye exams to detect problems  Macular Degeneration o Tiny yellowish spots beneath retina o Dry type (most common) and wet type o Clinical manifestations:  Wide range of visual loss  Loss of central vision o Nursing management:  Amsler grid  Patient instructed to stare at central fixation spot & report any distortion  Squares may look faded, or lines may be wavy  Test eyes frequently  Any change requires immediate attention  Glaucoma o Elevated intraocular pressure o If left untreated will lead to damage to optic nerve o Open-angle / Closed-angle o Open-angle  Clinical Manifestations:  “Silent thief of sight” – most unaware until loss of vision occurs  Blurred vision  Halos around lights  Difficulty focusing   Medical management: goal is prevention of blindness  Topical ocular medications to lower IOP o Pilocarpine causes blurred vision  Conjunctivitis o Inflammation of the conjunctiva o Characterized by a pink appearance o Types: Bacterial, viral, fungal, parasitic o Clinical manifestations:  Foreign-body sensation  Scratching or burning sensation  Itching  Photophobia o Nursing considerations  Wash hands Unit 7 Soft-Tissue Injuries Sprains & Strains Bone injuries and Infections Bone and joint trauma Back Pain Fractures Complications Compartment Syndrome Fat emboli syndrome Infections of the Bone Osteomyelitis Metabolic Bone Disease Osteoporosis  Paget Disease Osteomalacia Diseases of Skeletal Muscle Muscular Dystrophy Osteoarthritis Joint Dysfunction Secondary to Other Diseases Psoriatic Arthritis Gout Carpal Tunnel Syndrome Amputations  Sprains o Injury to ligaments and tendons surrounding a joint o Caused by twisting or hyperextension of a joint o Clinical manifestations: pain, swelling, discoloration o Grading system:  First degree – mild  Second degree – moderate  Third degree - severe o Nursing management: PRICE  Protection  Rest  Ice  Compression  Elevation  Back Pain o Caused by one of many musculoskeletal problems o Comorbidities: depression, smoking, alcohol abuse, obesity, stress o Clinical manifestations: acute back pain or chronic back pain, fatigue, radiculopathy, sciatica o Strategies for preventing acute low back pain:  Weight reduction  Walk daily  Stretch to enhance flexibility  Practice good posture  Push objects rather than pull  Keep load close to body when lifting  Change positions often  Avoid prolonged standing in one position  Hip fracture o Surgical intervention as soon as possible o Nursing management:   Pain management  Prevention of complications  Deep breathing to prevent pneumonia  Dorsiflexion and plantar flexion exercises  Antiembolism stockings  Anticoagulants to prevent VTE  Begin assisted ambulation first post-operative day  Compartment syndrome o May arise from:  Increase in compartment volume from edema or bleeding  Decrease in compartment size from restrictive cast o Perfusion to tissue is impaired causing cell death o Typically develops within 6-8 hours o Clinical manifestations:  Deep, throbbing, unrelenting pain, disproportionate to injury, worse with ROM o Assessment:  Pain  Pallor  Pulselessness – late sign  Paresthesia – early sign of nerve involvement  Paralysis o Medical management: surgical fasciotomy may be necessary  Fat embolism syndrome o Fat emboli enter circulation following orthopedic trauma, especially long bone fractures o Fat globules diffuse from marrow into vascular compartment o May occlude small blood vessels in lungs, brain, other organs o Onset of symptoms within 12-72 hours o Clinical manifestations:  Hypoxia  Tachypnea  Dyspnea  Tachycardia  Chest pain  Low-grade fever  Crackles  Respiratory failure o Treatment: supportive  Osteomyelitis o Infection of the bone o Results in inflammation, necrosis, formation of new bone o Risk factors:   Older adults  Poorly nourished  Obese  Impaired immune system  Diabetes (foot ulcer)  Rheumatoid arthritis  Corticosteroid therapy  Immunosuppressed  IV drugs  Osteoporosis o Loss of bone density o Consequence is bone fracture o Affected by genetics, nutrition, physical activity, medications, general health o Primary osteoporosis occurs in women after menopause, men later in life o Secondary osteoporosis is result of medications or diseases o Prevention:  Regular weight-bearing exercise  Reduce use of caffeine, tobacco products, carbonated soft drinks and alcohol  Increase intake of calcium and vitamin D  Paget disease o Disorder of localized rapid bone turnover o Most commonly affects skull, femur, tibia, pelvic bones, vertebrae o Cause is unknown o Clinical Manifestations: skeletal deformity of skull, bowing of femurs and tibiae, rigid spine o Medical management:  NSAIDs  Walking aids  Shoe lifts  PT  Alendronate therapy  Osteomalacia o Metabolic bone disease o Characterized by inadequate mineralization of bone o Skeleton softens and weakens o Clinical manifestations: pain, tenderness, bowing of bones, pathologic fractures o Medical management: treat cause  If kidney disease prevents activation of absorbed vitamin D – give calcitriol  If caused by malabsorption – increase vitamin D and calcium  Increase exposure to sunlight  If dietary – improve intake of vitamin D and calcium   Braces or surgery may be necessary to treat deformities  Muscular Dystrophy o Incurable muscle disorders o Characterized by progressive weakening, wasting of skeletal or voluntary muscles o Most are inherited o Clinical manifestations: muscle stiffness or weakness, dysphagia, mental deficits o Medical management:  Supportive care  Prevention of complications  Exercise program to prevent muscle tightness, contractures  Monitor respiratory status for infection  Osteoarthritis o Noninflammatory degenerative disorder of joints o Limited to affected joints – no systemic symptoms o Clinical manifestations: pain, stiffness, functional impairment o Medical management:  Decrease pain and stiffness  Maintain or improve joint mobility  Exercise  Weight loss  PT/OT  Assistive devices  1000mg acetaminophen Q 6 hrs  Psoriatic Arthritis o Inflammatory arthritis associated with skin disease psoriasis o Genetics is found to be strong predictor o Clinical manifestation: inflammatory backpain that occurs at night o Medical management:  Treatment of pain  Maintaining mobility  Suppressing inflammation  Exercise to maintain ROM  Muscle-strengthening  NSAIDs  Methotrexate  Gout o Common form of inflammatory arthritis o Incidence increases with age, BMI, alcohol consumption, hypertension, diuretic use o Caused by increased serum uric acid o Clinical manifestations: acute gouty arthritis, crystalline deposits accumulating in articular tissue (great toe) o Medical management:   Colchicine  NSAIDs  Avoid purine-rich foods  Weight loss  Decrease alcohol consumption  Carpal Tunnel Syndrome o Entrapment neuropathy of median nerve at wrist o Clinical manifestations: along thumb, index & middle fingers  Pain  Numbness  Paresthesia  Weakness o Treatment  Oral or intra-articular injection of corticosteroids  NSAIDs  Acupuncture  Wrist splints  Surgery  Amputations o Removal of a body part – usually digit or limb o Consequence of vascular disease (54%) or trauma (45%) o Used to relieve symptoms, improve function, save or improve patient’s quality of life o Performed at most distal point that will heal successfully o Complications: hemorrhage, infection, skin breakdown, phantom limb pain, joint contracture o Nursing interventions:  Relieving pain - Light sandbag on residual limb  Promoting wound healing – assess for edema  Enhancing body image – communicate acceptance  Helping patient resolve grief – create accepting and supportive atmosphere  Promoting independent self care – encourage patient to participate in self care