Med Surg Exam 3 Notes PDF
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Summary
These notes cover medical-surgical topics, including fluid resuscitation calculations, burn assessment, cerebral perfusion pressure (CPP), and altered level of consciousness (LOC) management. They detail treatment for ischemic strokes and increased intracranial pressure (ICP), along with monitoring and management strategies.
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EXAM 3 NOTES CALCULATIONS: URN FLUID RESUSCITATION B - ⇒ Electrical + Thermal burns 2 ml LR * weight (kg) * % TBSA … Chemical ⇒ double (4 ml LR) - TOTAL needs to be administered within 24 hours o...
EXAM 3 NOTES CALCULATIONS: URN FLUID RESUSCITATION B - ⇒ Electrical + Thermal burns 2 ml LR * weight (kg) * % TBSA … Chemical ⇒ double (4 ml LR) - TOTAL needs to be administered within 24 hours of INJURY - ½ within first 8 hours - ½ over next 16 hours - Ex: total = 2000 ml - 1000 ml in first 8 hours : 1000/8 = 125 ml/hr - 1000 ml in next 16 hours : 1000/16 = 62.5 ml/hr - BUT based on pt’s response… - Appropriate resuscitation: - Thermal + Chemical - Urine output 0.5-1 ml/kg/hr - Electrical - Urine output 75-100 ml/hr - hr/bp NOT useful in assessing intravascular volume of burn pts TBSA - RULE OF 9s… (Lund & Browder for peds) TOTAL = 100% - 1 arm = 9% - anterior / posterior = 4.5% - 1 leg = 18% - anterior / posterior = 9% - ANTERIOR chest (9) + abdomen (9) = 18% - POSTERIOR chest (9) + abdomen (9) = 18% - Genital area = 1% - Face = 9% - anterior / posterior = 4.5% PP (central perfusion pressure) C CPP = MAP - ICP (way to remember : med surg before ICU) t PA dosage(ISCHEMIC STROKES within 2 HOURS of s/sONSET… NOT arrival! … if onset unknown→ contraindicated) Dosage … 0.9 mg/kg (MAX 90 mg) 10% bolus over 1 minute … then 90% over 1 hour *ensure 2 IV sites prior to administration via infusion pump + frequent vitals/neuro checks *side effects: NO anticoags/platelet inhibitors + avoid tube/catheter placement for 24 hours NEURO CH 61 - NEURO DYSFUNCTION MANAGEMENT ⇒ ALTERED LOC not oriented, can’t follow commands,needs persistent stimuli for alertness - ** most important indicator of patient’s condition - Gauged on continuum from normal LOC → coma - Coma = unresponsive + unarousable - No purposeful response to internal/external stimuli - Intact internal structures of brain required for normal function** - Types… ⇒ - Akinetic mutism state of unresponsiveness to environment with lack of ability to move/speak but eyes may follow or be diverted by sound ⇒ - Persistent vegetative state pt resumes sleep/wakecycle after weeks in vegetative state with partial arousal but no true awareness ⇒ - Locked in syndrome pt conscious/cognitively intact+ has senses but has no function except blinking - Pathophysiology… - Disruption in nervous system cells, NTs, or anatomy - Multiple phenomena - Neuro → head injury, stroke - Toxicologic → OD, alcohol intoxication - Metabolic → DKA, hepatic, kidney - Depends on cause + placement on LOC continuum - s/s… - As state of LOC declines, changes occur in… - restlessness/anxiety, pupils slow to response to light / fixed if comatose, eye opening, verbal + motor response - As ICP increases, pt becomes more stuporous(reactingto only loud/painful stimuli) - Implies serious brain impairment + immediate intervention required - Abnormal posturing… - Decorticate= severe brain damage - plantar flexion, extension/internal rotation LE,flexionUE (elbow + wrist), adduction whole arm - Decerebrate= more severe damage ofnuchal spinaltract indicating lesion lower in brainstem - lantar flexion, extension/external rotation LE,extension elbow, p pronation forearm,wrist flexion - Increased ICP - Monro-Kelli hypothesis… - Increase in 1, causes decrease in one or both of others or increased ICP results - Tissue, blood, CSF - Pathophysiology… - Mostly d/t head injury - can be secondary to brain tumor, subarachnoid hemorrhage, toxic/viral encephalopathy - Decreases cerebral perfusion → further swelling - … herniation … ischemia + cell death - CO2 concentration in blood plays role in cerebralblood flow → vasomotor centers stimulated to increased bp??? → slow bounding pulse + resp irregularities - Cerebral edema - Abnormal fluid accumulation in intra/extracellular space/both d/t increase in brain tissue volume - Autoregulation to compensate… - Brain’s ability to change vessel diameter to maintain constant cerebral blood flow - **ONLY if systolic 100-150 + ICP < 40 - Cerebral perfusion pressure = MAP - ICP - If autoregulation ineffective + cerebral perfusion declines significantly… - Cushing’s response/reflex/triad ⇒ - bradycardia, hypertension, bradypnea - Assess … - Mental status - → GCS (scale of 3-15,≤ 8 = requires intubation + mech vent; mild=13-15) - Eye opening, verbal response, motor response - ex… E2, V4, M6 = 12 - **monitor trends to see where dysfunction lies - Cranial nerve function - Cerebellar function → balance + coordination - Reflexes - Motor + sensory function - d/x… - CT, MRI, MRS, EEG - ET or SPECT P - Transcranial Dopper study or cerebral angiography for cerebral blood flow - Lumbar puncture… - Usually avoided with LOC changesd/t increased ICPcausing herniation of brain - labs… - Blood glucose - Electrolytes - Ammonia + LFTs - BUN / creatinine - Calcium level - Coags + PT - t/x… - btain/maintain patent airway o - Maintain adequate oxygenation + ventilation - BP, HR to assess circulatory status - IV fluids/meds - Neurologic care - Nutritional support - Prevent complications - Lower ICP… - MonitorCSF volumethrough osmotic diuretics, restrictfluids, drain CSF carefully, reduce fever / metabolic demands - Detect early (ventriculostomy – intraventricular catheterinto lateral ventricle to measure ICP through transducer) for earlytreatment - Complications… meningitis, ventricular collapse, catheter occlusion (brain tissue, blood) - Aseptic technique when draining bag - Coughing discouraged because increases ICP - Decrease cerebral edema - Osmotic diuretics → mannitol or 3% NS - Assess for HF/pulmonary edema because are hypertonic solns - Ifbrain tumor is cause → corticosteroids - Maintaining hypothermia has not confirmed if effective but is still performed - Maintain cerebral perfusion - Dobutamine, norepinephrine to maintain CPP > 70 - Control fever d/t increasing metabolic demands - Antipyretics, hypothermia blankets,correct any shivering - Maintain oxygenation + reduce metabolic demands - High dose barbiturates if unresponsive to conventional sedatives→ requires continuous cardiac monitoring, ET intubation/mech ventilation, monitor MAP/ICP - Nursing Process - assess - verbal response, alertness, motor response - resp status, eyes (including edema), reflexes, body functions - d/x + plan/goals/evaluation - based on assessment data… - Ineffective airway clearance - Maintain airway → manage secretions, HOB 30, lateral or semi prone position, auscultate at least q8h, mech ventilation interventions - Risk for injury - Pad side rails (2 raised - 4 considered restraint if intent is to limit mobility, if a&ox4 and asks - then not restraint and can raise), identify potential sources of injury, ensure pt’s dignity during altered LOC - Fluid volume imbalance - IV fluids given slowly to reduce risk of increased ICP - Feeding tube if needed - Risk for imbalanced nutrition r/t inability to ingest food - Impaired elimination - Prevent urinary retention - Bladder palpation + scans regularly - Intermittent straight cath / indwelling to measure output (but increases infection risk) - Condom cath / primafit - As soon as continent → bladder training program initiated - Promoting bowel function - Assess regularly for distention, bowel sounds, girth with tape measure - Monitor #/consistency of BMs + rectal exam for s/s fecal impaction - Stool softeners (can be given with tube feeds) - Ineffective health maintenance - Restoring health maintenance - All senses (including kinesthetic) to stimulate pt emerging from coma - **once risk of increased ICP not an issue - Provide daily rhythm - Interrupted family processes - Meet family’s needs - einforce/clarify information + validate R - Encourage family involvement in talking + touching pt - **unless stimulation disturbs/agitates pt - Allow for frequent rest periods ⇒ - Brain dead irreversible brain dysfunction (can be pronouncedbeforeheart stops beating) - (risk for) impaired skin integrity - Mouth care to prevent infection - inspect for dryness/inflammation/crusting - cleanse/rinse carefully to remove secretions/crusts + keep membranes moist - Thin layer of petroleum - Move ET tube to opposite side of mouth daily to prevent ulcerationof mouth/lips - Maintain skin + joint integrity - Regular turning schedule + correct positioning + passive ROM - Foam boots, trochanter rolls to prevent contractures - Maintain body temp → fever increases metabolic needs + insensible fluid loss - Minimal bedding used + lower room temp if pt has fever - Administered acetaminophen/ibuprofen - Cool sponge baths - Hypothermia blanket - Monitor temp frequently - Preserve corneal integrity to prevent ulceration - Clean with cotton balls moistened with sterile NS to remove debris/discharge - Preventcomplications - Include ⇒ - brainstem herniationd/t increased ICP in cranial bulb blocking blood flow to brain - neurogenic diabetes insipidusd/t decreased ADH secretion - Increasedurine output + urine osmolality …FVD - > 200 ml/hour for 2 consecutive hoursmay indicate diabetes insipidus onset - SIADHd/t increased ADH - Decreasedurine output +decreased serum Na conc …FVE - Close vital sign monitoring - CBC/ABGs monitoring - Chest physiotherapy, suctioning, mouth care - Assess skin integrity frequently + turning + moisture protection - Monitor s/s VTE + prevent - ⇒ Prevent contractures passive ROM per shift SEIZURE DISORDERS ⇒ - sudden, uncontrolled episodes of abnormal motor/sensory activity d/t electrical disturbance in brain ⇒ - Epilepsy 2 unprovoked seizures > 24 hours apart - Types… - Focal ⇒ - Generalized both hemispheres - Unknown - Provoked (acute reversible condition - structural/metabolic/infectious etiology) vs Unprovoked - Causes include… - CV disease - Hypoxemia - Fever in childhood - TBI - HTN - CNS infection - Brain tumors - drug/alcohol withdrawal - Allergies - s/s… - Depends on location of discharging neurons - Generalizedabsence→ simple staring episode to prolongedconvulsive movements with loss of LOC - Generalizedtonic-clonic seizure→ intense rigidityof entire body + alternating mm. relaxation/contraction - bite tongue, incontinent - Usuallysubsides after 2 min and enters postictalstate(sleepy + hard to arouse, headache/fatigue/depression after awaken) - assess… - type of seizure, frequency, severity, precipitating factors - h/x events + pregnancy/childbirth h/x + PMH - d/x… - CT/MRIforstructural/focal abnormality - EEG→classifyseizure - SPECT→identify zonesof brainproducing seizures - nursing management… - during seizure - Observe + record + document sequence of events!! (before, during, stimuli, aura noted, body parts involved, incontinence, pupil responses, duration) - Observe + record + document postictal stage - Administer meds - Injury prevention… - Hypoxia + aspiration → lateral position + suctioning + nothing in mouth - Side rails padded - Allow rest Status Epilepticus (SEIZURE) ⇒ - series of generalized seizures occurring withoutfull recovery of LOC between attacks= medical emergencyd/tpotential irreversible damage** - causes… - Missing anticonvulsant med dose - Fever / infection - t/x… - Goal=stop seizures asap+ ensurecerebral oxygenation+ maintainseizure-free state - IV benzodiazepines - Preventseizure →phenytoin, phenobarbital - EEG + ECG monitoring - IV dextrose if d/t hypoglycemia - nursing management… - Protect from injury - Prevent aspiration - Monitor IV line d/t potential dislodgement during seizure - pt education… - Long term anticonvulsant use causes increased fracture risk d/t bone disease (OP, osteomalacia, hyperparathyroidism) HEADACHE - = most common of all human physical complains (s/x rather than disease) - Cranial arteritis = common cause - s/s usually begin more general → fatigue, malaise, weight loss, fever ⇒ - Primary headache no organic cause identified - Includes ⇒ - Migraine characterized byperiodic / recurrent attacksofsevere headache fromhours - daysin adults withphotophobia and nausea ⇒ - Tension headache most common,chronic,less severe - Trigeminal Autonomic Cephalalgia ⇒ - Cluster headache relativelyuncommon+M > F ⇒ - Paroxysmal hemicrania recurrent, unilateralheadacheattacks that are typicallyshort in duration (2-30 min)but canoccur frequently throughout the day - s/s… - migraine w/ aura, 4 phases: - 1)premonitory - experienced by> 80% adult migraine sufferers - s/soccurhours-days before headache phase - 2)aura phase - characterized byfocal neurologic s/s + visual disturbances– most common +hemianopic (half of visual field) - 3)headache phase - severe + incapacitating. associated withphotophobia,phonophobia, perception of innocuous stimuli → N/V - 4)postdrome phase - pain gradually subsides - weak, fatigue, cognitive disability, mood changeshours-days - Tension-type - steady/constant pressureinforehead/temples/backof neck - “weight in top of head” - cluster headache - unilateral - 8-10/day → lasts 15 min-3 hourswithcrescendo/decrescendopattern - pain ineye/orbit radiating to facial/temporalregions - pluswatery eyes + nasal congestion - t/x… - Abortive approach=relieve/limitheadache at onset/whilein progress - Preventive approach= experience more frequency attacksat regular or predictable intercans OR contraindicated for abortive therapy - ex…triptansused forvasoconstriction, reduce inflammation,reduce pain transmission - 1st line for moderate-severe migraine pain - Contraindicated withHTN → preventive approach instead - other meds: - Ergotaminepreparation → PO, SL, SQ, IM, PR, inhalation - Effective foraborting headache if taken early - Preventive → anticonvulsants, beta blockers, antidepressants - Forcluster headaches… - 100% O2 by face mask for 15 min - SQ sumatriptan - intranasal med - Forcranial arteritis… - Corticosteroidsto reduce inflammation and preventocclusion →can cause vision loss - nursing management… - Goal = pain relief - 1st priory = t/x acute event - 2nd priority = prevent recurring episodes - Education… - Understand precipitate factors + make lifestyle factors (ex: smoking, chemical exposure) - Pain relief depends on type of headache… - Migraine = abortive meds in early phased/t causingN/V and uncontrollable pain later in headache ⇒ - Comfort measures anti nausea med, dim light/noise, HOB 30 - Tension headache - Local heat or massage ⇒ - Other strategies analgesics, antidepressants, muscle relaxants CH 62 - CEREBROVASCULAR DISORDER aka STROKE MANAGEMENT - CH 63 - NEURO TRAUMA MANAGEMENT - ead injury = any damage to head d/t trauma (doesn’t have to be to brain) H - ⇒ TBI injury d/t external force that interferes with daily life ⇒ - Primary injury consequence ofdirect contact - Ex: laceration, contusion, external hematoma, skull fracture, subdural hematoma, concussion ⇒ - Secondary injury evolves over timed/t inadequateO2/nutrient deliveryto cells - Monro-Kellie Hypothesis… - Cranial vault = closed system with brain, blood, CSF - If any component increases in volume, one or both of others must decrease or ICP will increase … leads to anoxic brain cells … causing ischemia, infarction, herniation, brain death - SCALP INJURY - Minor injury - S calp bleeds profusely d/t poorly constricting blood vessels (causing it tolook more serious than it may be) - Large avulsion can be fatal though - Infection risk / portal of entry ⇒ - Subgaleal hematomas blood collection under skinbut above skull - … usuallyreabsorbs without any specific treatments - SKULL FRACTURES - Break in skull continuity d/t forceful trauma - Classified by… - Type - Linear ⇒ - Comminuted splintered/multiple fracture lines ⇒ - Depressed bones of skullforcefully displaced downwardoccupying space in cranial vault - Location - Frontal - Temporal - Basal… *** NG tube insertion contraindicated!! - s/s… - Cranial vault fractures may (not) produce swelling in region of fracture - Basal skull fracture→ hemorrhage in nose, pharynx,ears, or under conjunctiva - can includeCSF leakage… bad! - meningeal infection can occurif pathogens gain accessto cranial vault ⇒ - Battle sign ecchymosis over mastoid bone - Gerontologic considerations… - Difference in etiology - Mostly d/t MVCs and falls - Higher mortality + longer hospital stay - Poor functional outcomes - Neuro assessment challenges → preexisting cognitive issues, visual/auditory deficits - Fall risk - Anticoag/antiplatelet agents increase bleeding risk - t/x… - Close monitoring ⇒ - Non-depressed skull fracture no surgical t/x ⇒ - Depressed skull fracture elevate skull + debridewithin 24 hours - BRAIN INJURY - Contusion / Closed Head Injury= bruised area d/tacceleration/deceleration force or blunt trauma … brain tissue damaged but NO opening through skull - Contusion peaks in 18-36 hours - Assess → increased ICP noted by stupor/confusion - enetrating / Open Head Injury= object penetrates skull, enters brain, damages tissue P - Intracranial Hemorrhage= collection of blood in brain - s/s occurwhenhematoma large enough to cause braindistortion+ increased ICP - Usuallydelayed assessment d/t needing blood to collectto cause s/s - types… - Epidural hematoma= betweenskull + dura mater - s/s →brief loss LOCwithperiod of lucidnesswhile compensation occurring (d/t rapid CSF absorption to decrease ICP)→ restless, agitated, confused → coma, herniation→ declining LOC, dilated/fixed pupils, paralysis of one extremity - Emergency requiring immediateintervention… - Burr holes - Remove clot + control bleeding - Subdural hematoma= betweendura + brain - d/t trauma, coagulopathies, aneurysm rupture - Types… - Acute - Early loss of LOC,pupillary changes,hemiparesis - Emergency needingimmediate craniotomy + clot removal - Chronic - d/t minor injuries, coagulopathies - Less bleeding + venous in nature - Often mistaken for stroke - s/s→personality changes, focal seizures, headaches - t/x→Burr holes→craniotomy if needed - Concussion= temporary loss of neurological functionwithout structural brain damage - Nursing management… - Observe + monitor trends/LOC - Pt education… - Monitor LOC - s/s to seek medical help → worsening headache, dizzy, seizures, abnormal/uneven pupil responses, headache vomiting, slurred speech, weakness/numbness, irritability - Diffuse Axonal Injury - d/twidespread shearing + rotational forces producingbrain damage + increases ICP - s/s… severe head trauma withno lucid interval + nocoma + decorticate/decerebrate posturing, global cerebral edema - d/x… CT, MRI, PET (in some trauma centers) - t/x… - MaintainC-spine alignmentwith cervical collar!!! - Assume spinal cord injury until r/o - GOAL =prevent secondary brain injury + maintain homeostasis - Supportive measures… - ventilation/intubation, seizure precautions, fluid/electrolyte management, nutritional support, pain/anxiety management, NGT to… - promote GI motility + prevent reverse peristalsis → regurgitation / aspiration risk / increases ICP - Sedation… - benzodiazepines used d/t not affecting cerebral blood flow or ICP - However, can produce toxic metabolites therefore… - Preferred sedation = PROPOFOL ⇒ - Brain dead potential organ donor - 3 cardinal signs of death: - 1)coma - 2)absence of brainstem reflexes - 3)apnea - Nursing Process… - Assess … head to toe including GCS - Nursing d/x … ineffective airway clearance, FVD, risk for injury - Too little/too much suctioning can increase ICP - Oral care to prevent VAP - Nutritional support d/t pt being in catabolic state - Maintain CPP between 50-70 mmHg - Prevent post traumatic seizures → can further increase ICP + cause secondary injury - SPINAL CORD INJURY - = injury to spinal cord, vertebral column, supporting soft tissue, or intervertebral discs - Commonly d/t MVC, falls, violence, sports - Risk factors - M gender #1 - Alcohol / drug abuse - May lead to paraplegia or tetraplegia - …bladder control loss, urinary retention/distention - Lose sweating/vasal motor tone below level of injury - Marked reduction in BP d/t reduced peripheral vascular resistance - s/s.. - Depends on type/level of injury - c omplete spinal cord lesion→loss of both sensory + motor communication - Incomplete spinal cord injury→some abilityof spinalcord to relay messages ispreserved - Injuries toT12 and abovewillimpact respiratoryfunction - C4 injury=permanent ventilation requiredd/t innervating diaphragm - T1-T6innervates intercostals - T6-T12innervates abdominal muscles - Spinal cord endsatL1 - t/x… - R apid assessment, immobilization, stabilizationtoprevent secondary injury - Maintain cardiac/resp function - Meds… - High dose IV corticosteroids - O2to prevent hypoxemia + worsening neuro deficit - Skeletal fracture reduction/traction→ensure weightsare unencumbered to maintain correct alignment - Surgical intervention if… - compression of spinal cord, results infragmented/unstable vertebral bodies, wound/bony fragments in cord, neuro status deteriorating - Complications… - Spinal shock ⇒ - sudden depression of reflex activity in spinal cord …muscles below injury paralyzed, flaccid, without sensation - Neurogenic shock ⇒ - lose autonomy nervous system functionbelow levelof lesion … vital organs affected - hypotension, bradycardia, no sweatingbelow levelof injury due to blocked SNS - risk for VTE but same as risk for those with other traumatic injuries - Nursing Process… - Assess → airway, breathing, neuro exam - d/x → ineffective breathing pattern, impaired mobility, risk for injury - AUTONOMIC DYSREFLEXIA with SPINAL CORD INJURY - fatalemergency - =exaggerated response to stimuli harmless to thosewithout SCI - Occurs in pts withlesion above T6, after shock subsided - T riggers → distention of visceral organs (especially bowel), distended bladder, skin stimulation (pressure) … all causing pain - Often d/t kinked foley catheter - s/s… - Pounding headache, paroxysmal hypertension, profusediaphoresis ABOVE level of lesion, nausea,nasal congestion, bradycardia - nursing interventions… - Remove trigger - Reposition / examine skin, empty bladder, examine rectum for fecal mass, administer antihypertensives - Document + pt education CH 64 - NEURO INFECTIONS, AUTOIMMUNE DISORDERS, NEUROPATHY MANAGEMENT - INFECTIONS - MENINGITIS= inflammation of the meninges - 3 causes: bacterial, viral, fungal - Septic (bacterial) or aseptic (viral, secondary to cancer/weak immune system like in HIV /AIDS) - Aseptic more frequent in summer + early fall - Septic peaks in winter + early spring - Dense community groups → college campuses + military bases - s/s… - Headache, fever,nuchal rigidity, photophobia, rashwith some types, disorientation/memory loss → lethargy/coma with progression ⇒ - positive Kernig sign pt supine with hip flexed andknee at 90 degrees - Positive = leg can’t be completely extended without pain - If bilateral pain —> meningeal irritation expected ⇒ - positive Brudzinski extension of neck causes hips+ knees to flex - More sensitive indicatorfor meningeal irritationthan Kernig, BUTboth NOT reliable - Prevention… - Meningococcal vaccine for 11-12 y/o with booster at 16 y/o - Ifclose contact→rifampin / ciprofloxacin / ceftriaxonewithin 24 hours - t/x… - Earlyantibiotics that crosses BBB and passes subarachnoidspace - Penicillin GandIV cephalosporin 3rd gen - Dexamethasone→before 1st dose of antibiotics thenrepeated q6h for 4 days - Blunts inflammatory response d/t bacterial lysis + improves outcomes - If hypovolemic / shock → volume expanders - Nursing management… - Dropletprecautionsfor24 hours after antibiotictherapy - Pneumococcal meningitisNO isolationrequired - BRAIN ABSCESS - =collection of infectious material within brain tissue - Rare if immunocompetent →occurs mostly in immunocompromisedpts - d/t intracranial surgery, penetrating head injury, tongue piercing - mostly d/t otitis media + rhinosinusitis - s/s… - d/t abscess location, cerebral hemodynamic alterations - Headache usually worse in morning, fever, vomiting, focal neuro deficits (weakness, vision loss), s/s increased ICP with progression → declining LOC + seizures - t/x… - ControlICP - Drain abscess - Antibiotics - Corticosteroidsto reduce cerebral edemaif evidenceof increased neuro deficits - Anticonvulsantstot/x or prevent seizures - HERPES SIMPLEX ENCEPHALITIS - =inflammatory process of brain tissue - Most common cause in US = herpes simplex - leads to →necrotizing hemorrhagewithprogressivedeterioration of nerve cell bodies - s/s… ⇒ - Early fever, headache, confusion, hallucinations ⇒ - Late as necrosis develops behavioral changes, seizures,dysphasia, hemiparesis, altered LOC - t/x… - Antiviral agents (ex:acyclovir) for 3 weeks to preventrelapse - Slow IV administration over 1 hour to prevent crystallization in urine - Lower dose if renal insufficiency - Nursing interventions… - Frequent neuro assessments - Dim lights, limit noise/visitors, group care - Pain relief …caution with opioids d/t masking neuros/s - Monitor for renal complications - Seizure precautions to prevent injury - ARTHROPOD-BORNE VIRUS ENCEPHALITIS aka ARBOVIRUSES - /tblood-feeding arthropods (mosquitos, biting flies, ticks) → St. Louis + West d Nile - s/s on continuum… - Flu s/s → coma - SIADH with hyponatremia - t/x… - No cure - s/s management →control seizures + ICP - meds… - Interferon for St. Louis encephalitis - Usually on outpatient basis - Nursing interventions… - Identity improvement/deterioration - Prevent injury - Pt education… - Can cause death + life long complications if progresses - Prevention… - long sleeve clothing outside, insecticide in high risk areas, remain indoors at dawn/dusk, screens on windows, standing water around home removed - ALL cases of arboviruses must be reported to health department - AUTOIMMUNE PROCESSES - MULTIPLE SCLEROSIS - =immune mediated, progressive, demyelinating diseaseof CNS - Impairs nerve impulses - Risk factors… - F > M - Genetic factors but not genetically transmitted - Environmental exposure →Epstein Barr virus, smoking,vitamin D deficiency - s/s… - Fatigue, depression, weakness, numbness, incoordination, spasticity, pain, paresthesia - Visual disturbances d/t lesions on optic nerve and/or connections→ diplopia, blurry vision - Types… - Relapsing-remitting (RR) - 85% - acute attacks with full recovery - residual effectswith each relapse mayaccumulateover time causingfunctional decline - Primary progressive - 15% - s teadilyprogress without plateaus and temporary minor improvement - Secondary progressive - begins withRR followed by variable progression rate - May cause →quadriparesis, cognitive dysfunction,visual loss, brainstem syndromes - Progressive relapsing - 5% (least common) - Relapseswithcontinuous disabling progressing between exacerbations - t/x… - G OAL = delay progression of disease, manage chronic s/s, t/x acute exacerbations - No cure for MS - Disease modifying therapy→ reduce relapse incidence/duration+ #/size plaques on MRIin RR - NOT effective in progressive forms - IV methylprednisoloneeffective forRR acute relapses→shortens relapse durationbutno long term benefits ⇒ - Side effects mood swings, weight gain, electrolyte imbalance - Baclofen→ spasticity - Beta blockers,anticonvulsants (gabapentin),benzodiazepines (lorazepam)→ ataxia - Anticholinergics/alpha blockers/anti osmoticsagents→ bowel/bladder problems - Vitamin C / ascorbic acid→ reduce UTI risk - Gerontologic considerations… - 5-7 year shorter life expectancy than those without MS - Absorption, distribution, metabolism, excretion of meds may be altered d/t age-related kidney/liver changes - Medication noncompliance r/t high cost - Depression d/t familial burden, marriage concerns, disability, isolation - Increased need for assistance with self-care - MYASTHENIA GRAVIS - =autoimmune neuromuscular disease causing muscleweakness - acetylcholine receptorantibodiesproduced, disruptingmotor function - s/s… - Diplopia,ptosis (droopy eyelids), facial/throat muscleweakness causes bland facial expression,dysphonia,dysphagia - Generalized weakness + decreased vital capacity + potential resp failure - MOTOR disorder, NOT sensory or coordination - t/x… - GOAL = improve function + remove circulating antibodies …NO cure - nticholinesterase + immunosuppressive therapy A - IVIG - TPE (therapeutic plasma exchange)to t/x exacerbations - ⇒ Surgical management thymectomyto reduce antibodyproduction - ONLY t/x resulting incomplete remission in 35% pts - Complete thymus gland must be removed - Nursing interventions… - Prevent complications + pt/family education for outpatient… - Energy conservation - Medication compliance →take at SAME time every day otherwisecan lead to acute resp failure - Prevent ocular complications - GUILLAIN-BARRE SYNDROME - =autoimmune attack on the peripheral nerve myelin - Rapid segmental demyelination of peripheral nerves - → ascendingweakness with dyskinesia(can’t makevoluntary movements),hyporeflexia,paresthesias - s/s… - Muscle weakness + diminished reflexes in LE progressing up - Cranial nerve demyelinationmaycause blindness - peak s/s severityin2 weeks,lasts 4 weeks, usuallyself-correcting - t/x… - d/t potential ofrapid progression, considered a medicalemergency - RT + mech ventilation may be necessary - Somemay recommend elective intubation before onsetof severe respiratory mm fatigue - Other interventions to prevent mobility complications… - Anticoagulants - SCDsto prevent VTE/DVT - CRANIAL NERVE DISORDERS - TRIGEMINAL NEURALGIA - Involves5thcranial nerve - Suddenpain to areasinnervated by any3 branchesof nerve - Pain characterized byunilateral shooting, stabbing,burning sensation - Risk factors… - Mostly d/t age (50s-60s) - F > M - pts with MS - Attacksworsen with progression→ pt may be infearof having sudden attack - Triggers… - touching/shaving, chewing/drinking, speaking, brushing teeth,even a breeze - t/x.. - t egretol (anticonvulsant)toreduce nerve impulsetransmission - gabapentin + baclofenforpain control →phenytoinasadditive if needed - Surgical options… - microvascular decompression of trigeminal nerve - percutaneous balloon microcompression - radiofrequency thermal coagulation - Nursing interventions… - pain control on outpatient basis - pt education aboutprevention→room temp water towash face, use mouthwash post-eating if toothbrushing painful,personalhygiene during pain-free intervals, soft foods /chew on unaffectedside, food/fluids atroom temp - BELL PALSY - Involves7thcranial nerve - =unilateral facial paralysis - Possible link to vascular ischemia, autoimmunity, herpes viral infections - Usually inpts < 45 y/o - s/s.. - Painful sensationto facebehind ear/in eye,speech/swallowing difficulties,facial paralysis/distortion,tearing/lacrimationoccurs - Usuallyspontaneous recovery in 3-5 weeks - t/x… - corticosteroids (prednisone)mayreduce severity (inflammation/edema/reduce vascular compression + restore blood flow) - GOAL =maintain facial mm tone,prevent/minimize denervation - Assure that pt did NOT have stroke and recovery in 3-5 weeks - Analgesics for pain control - Nursing interventions… - Protect eye from injury with paralysis (can’t close eyelids) →protective eyewear at night + moisturizing eye drops in AM - Massage facewith gently upward motion tomaintainfacial mm tone / prevent atrophy - Prevent breeze/cold exposure CH 65 - ONCOLOGIC or DEGENERATIVE NEURO DISORDER MANAGEMENT ONCOLOGIC - BRAIN TUMORS - Over 100 different types ; 80,000 diagnosed / year (⅓ malignant,⅔ benign) - ⇒ Primary originate from cells within brain - s/s… ⇒ - Increased ICP headache, vomiting, visual disturbances,seizures - focal/localized s/s… ⇒ - Parietal decreased sensationonopposite side ofbody ⇒ - Temporal seizures, psych disorders ⇒ - Occipital visualmanifestations ⇒ - Cerebellar dizziness, ataxic gait - t/x… - Surgery - Remove as much of tumor as possiblew/o increasingneuro deficit + relieve s/s - Radiation(if can’t be removed completely) - Decreases incidence of recurrenceofincompletelyresected tumors - Chemo - Increases survival time+ can be incombo with radiation - BBB provides challenge for effective chemo without systemic toxicity - Meds - Corticosteroidsreduce inflammation - Osmotic diureticsdecreased fluid content - Anticonvulsantsforseizures - Nursing interventions… - Neuro assessment + maintaindocumentationto monitortrends - includingtype of tumor, progression, pt’s wishes - Manage pain → positioning, medication, alternative therapy - Manage N/V - Prevent aspiration - food/fluids to unaffected side, upright positioning during meals, suction equipment available - Pt education - Types… - Gliomas (30%) - Infiltrate surrounding neuro connective tissue+difficultto remove without causing significant damage - M > F;50-60 y/o - t/x +prognosis dependson type/stage of tumor - Combination ofchemo, radiation, surgery - Meningiomas (15%) - Encapsulated + slow growing - F > M;middle-aged - t/x =surgical removal + may add radiation - Acoustic neuromas - =tumor of 8th cranial nerve - Slow growing + benign ⇒ - s/swhentumor large hearing loss, tinnitus, vertigo, staggering gait, facial numbness ⇒ - t/x surgical removalwithgood prognosis - Can addstereotactic radiotherapy - Pituitary adenomas - Most slow growing + benign (rarely malignant) - Common amongF of child-bearing age - s/sd/tpressure on nearby structuresas they grow+vary on based of hormone released ⇒ - headache, visual disturbances, N/V, sexual dysfunction/infertility, fatigue, nasal drainage, smell changes, sleep/behavioral changes - elevated GH→gigantism in children+acromegaly inadults - elevated TSH→hyperthyroidism - elevated ACTH→Cushing's disease - Gerontologic considerations… - Incidenceof all brain tumorsincreases with advancingage - Early s/smay beoverlooked/associatedwithnormalaging process ⇒ - personality change, confusion, gait disturbance, speech dysfunction - Most commonbrain tumors… - Anaplastic astrocytoma - Glioblastoma - Cerebral metastases - ⇒ Secondary (metastatic) originate from lung, GI tract,pancreas, kidney, skinand metastasize to brain - 2x as commonasprimary tumors ⇒ - Leptomeningeal metastases metastasis to CSF + meninges ⇒ - s/s headache, isolated cranial nerve deficits - s/s… - Headache, gait disturbances, visual impairment, personality changes, altered mentation, focal paralysis, aphasia, seizures - t/x… - Palliative→ eliminate/reduce symptoms - steady decline + limited survival without t/x - 1st line→whole brain radiation therapy - vs… stereotactic radiotherapy (targeted directly at tumor) - single metastasis→surgery - Systemic chemomay be added, either… - directed to primary cause NOT crossing BBB - OR,crosses BBB / intrathecal (directly into CSF /spinal tract) - effective for leptomeningeal metastases - Nursing process… - Assess : neuro function, fluid balance, nutritional status (tolerance, preferences), impact on social/home life/self-care - Diagnoses : pain, self care deficit, imbalanced nutrition - Planning : manage pain, compensate for self-care deficits (increase autonomy) + disrupted family processes (pt/family education + encourage familial involvement), improve nutritional status - Evaluation - Verbalized relief of pain, use of assistive devices, eats/accepts alternate nutrition - SPINAL CORD TUMORS - Classified according to anatomical region… ⇒ - Intramedullary within spinal cord+usually primary ⇒ - Extramedullary / intradural within or under spinaldura ⇒ - Extramedullary / extradural outside dural membrane - Pressure causes localized s/s + progressive loss of motor + sensory function… - Pain, weakness, loss of reflexes BELOW level of tumor - Progresses toparalysis + loss of bowel/bladder function - t/x… - Medical: - Primary tumor=surgical - Chemo + radiationmay be used asfollow up ⇒ - Pain relief for spinal cord compression high dosedexamethasone + radiation - Nursing: - Post-op care - Neuro assessment + pain control ⇒ - Monitor + managecomplications abnormal breathing,urinary retention, bleeding, CSF leakage - Assess post-d/c needs DEGENERATIVE DISORDERS - PARKINSON DISEASE - Slow growing progressive neuro movement disorder - decreased dopamine levels→altered voluntary movement - M > F,s/s usually in 50s y/obut may beas earlyas 30 y/o ⇒ - s/s tremor, rigidity, bradykinesia, postural instability, sweating, drooling, gastric/urinary retention - t/x… - O t/x prevents progression; t/x only for controlling s/s +improving N independence/QOL - Meds… - Goal = restore dopaminergic / cholinergic activity balance - Levodopa (most effective agent)→converts dopaminein basal gangliafor s/s relief - Peak effects in first few years of t/xbutadverseeffects increase severity over time ⇒ - Within5-10 yrs, developdyskinesia facial grimacing, rhythmic jerking movement of hands, head bobbing, lip smacking / lip chewing - Therefore,levodopa delayed as much as possible before initiating - Carbidopa→ often added toprevent metabolism of levodopa before reaching brain - Surgical… - Deep brain stimulation→surgical implantation ofan electrodeto stimulate dopamine - HUNTINGTON DISEASE - Chronic, progressive, hereditary disorder→degenerationof nerve cells in brain - Inherited throughautosomal DOMINANT gene - s/s… - motor dysfunction (chorea),cognitive impairment,mood changes, behavioral feature - gait/speech become impaired/impossible - High suicide riskinearly disease process - Death usually d/t… - HF, pneumonia, infection, falls, aspiration - t/x… - Goal =optimize QOL + relieve s/s + prevent progression - NO cure - tetrabenazine→choreas/s - SSRIs + TCAs→depressives/s - AMYOTROPHIC LATERAL SCLEROSIS (ALS) - akaLou Gehrig disease - unknown cause - causes breakdown of nerve cells→reducing musclefunction - Risk factors… - Smoking - 40-60 y/o,M > F - Viral infections - Autoimmune disease - T oxin exposure - s/s… - Fatigue, progressive muscle weakness, twitching, incoordination, muscle atrophy - 25% ptsexperiencecranial nerve involvement 1st→dysphasia, dysphagia, eventually dyspnea - t/x… - goal = optimize QOL + relieve s/s + prevent progression - NO cure - Discuss EOL issues - Meds… - Riluzole (glutamine agonist)→prolong life 3-6 months - Baclofen, dantrolene, diazepam→ improve spasticity - Modafinil→improve fatigue - Outcomes.. - only30% ptshave5 year survival rate - 10-20%liveup to 10 years - 5%survive> 20 years MUSCULOSKELETAL CH 35 - MUSCULOSKELETAL ASSESSMENT - AP overview - Includes bones, joints, muscles, tendons, ligaments, bursae ⇒ - MS System Functions support body structures + protect vital organs ⇒ - Muscles + tendons allow joints to move - Movementfacilitates return of deoxy blood to R sideheart+produce heatto maintain body temp - > 89% total body Ca stored in bone - diseases/injuries involving MS system → commonly result in disability + death - 2.1 million visits / year to ED for falls - Bone Structure + Function… - 206 bones … made up of cells, protein matrix, mineral deposits ⇒ - Osteoblasts secrete bone matrix(collage + groundsubstances) ⇒ - Osteocytes mature bone cellsinvolved inbone maintenance ⇒ - Osteoclasts multinucleated cellsinvolved indissolving/resorbing bone - 4 bone categories… - 1)long= UE + LE - diaphysis(shaft) =cortical bone(exists wheresupportneeded) - piphyses(ends) =cancellous / trabecular bone(h e ematopoiesis + bone formationoccurs here) - Epiphyseal plateseparatesdiaphysis from diaphysis during childhood - articular cartilagecovers ends =tough, elastic,avascular - 2)short= ankles + hands - 3)flat=locatedwhereprotection of underlying structureneeded - 4)irregular= vertebrae + jaw bones - bone marrow(vascular)= inlong shafts of long +short bones - Bone Formation + Maintenance - Bone = dynamic tissue = constant state of remodeling - Peak bone massreached inearly 20s - Bone resorption > bone formationbeginning35-40 y/o ⇒ - Osteogenesis bone formation - Begins before birth ⇒ - Ossification bone matrix formation+crystallizationof Ca/P —> collagen fibers - Ca/P for strength;collagen for resistance - Balance of bone remodeling influenced by… - Complete turnoverof skeletal system =10 years - Physical activity (weight bearing activities supportsbone maintenance) - Ex: walking, running - Weight resistance = lifting weights - Diet - Ca: 1000-1200 mg/dayrecommended to maintain bonemass ⇒ - Recommended sources low-fat milk, yogurt, cheese, Ca-fortified OJ/cereal/bread, green leafy veggies - Vitamin D: 600 IU/day = adults ; 800-1000 IU/day = older adults ⇒ - Recommended sources sunlight, fortified-milk (not on it’s own),
