Transcript Nursing of Adults with Medical & Surgical Conditions

Nursing of Adults
with
Medical & Surgical Conditions
Neurological
Disorders
Laboratory and Diagnostic Exams
• Blood and Urine
– Culture
• Urinary tract infection
– Drug screens
• Rule out drugs as cause of symptoms
– Arterial Blood Gases
• Monitor the oxygen content of the blood
• Low levels indicate altered breathing patterns
• Cerebrospinal Fluid
– Normal Values
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Specific gravity:
pH:
Chloride:
Glucose:
Pressure:
Total Volume:
Total Protein:
Gamma globulin:
Cell Count:
– RBC
– WBC
1.007
7.35 to 7.45
120 to 130 mEq/L
50 to 75 mg/dl
80 to 200 mm water
80 to 200 ml
5 to 45 mg/dl
6% to 13% of total protein
None
0-10 cells (lymphocytes and monocytes)
• Cerebrospinal Fluid (Cont)
– Elevated lymphocytes may indicate infection
– Decreased chloride and glucose levels may
indicate tuberculosis meningitis
– Culture or smear is done to determine the
causative organism in meningitis
– Protein is elevated with degenerative disease or
brain tumors
– Blood indicates hemorrhage from somewhere in
the ventricular system
– Protein electrophoresis may give evidence of MS
• Computed Tomography (CT) Scan
– Detects pathological conditions of the cerebrum
and spinal cord
– May be done with or without contrast
• Brain Scan
– Uses radioactive isotopes
• MRI Scan
– Uses magnetic forces to image the cerebrum and
spinal cord
• PET Scan
– Positron Emission Tomography
– Used following stroke, Alzheimer’s, epilepsy and
Parkinson’s
– Injection of deoxyglucose with radioactive fluorine
is given
– Color scan is done; different shade can be
translated into different pathological conditions
• Lumbar Puncture
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Obtain CSF for examination
Relieve pressure
Inject dye or medication
Contraindicated in patients with increased
intracranial pressure
• Electroencephalogram (EEG)
– Used to provide evidence of focal or generalized
disturbances of brain function by measuring the
electrical activity of the brain
– Epilepsy, mass lesions, cerebrovascular lesions and
brain injury
– Procedure
• Patient is kept awake the night before
• Hair and scalp must be clean
• Electrodes are placed on the scalp
• Myelogram
– Used to identify lesions in the intradural or
extradural compartments of the spinal canal by
observing the flow of radiopaque dye through the
subarachnoid space.
– Used to diagnose herniated or protruding
intervertebral disk. Spinal tumors, adhesions,
bony deformations, and arteriovenous
malformations
– Lumbar puncture is performed, dye injected, and
fluoroscopic and radiopaque films are taken
• Angiogram
– Used to visualize the cerebral arterial system by
injecting radiopaque material
– Allows the detection of arterial aneurysms, vessel
anomalies, ruptured vessels, and displacement of
vessels by tumors or masses
• Carotid Duplex
– Uses combined ultrasound and pulsed Doppler
– Noninvasive study that evaluates carotid occlusive
disease
• Electromyogram (EMG)
– Used to measure the contraction of a muscle in
response to electrical stimulation
– Provides evidence of lower motor neuron disease;
primary muscular disease; and defects in the
transmission of electrical impulses
• Echoencephalogram
– Uses ultrasound to depict the intracranial
structures of the brain
– Detects ventricular dilation and a major shift of
midline structures in the brain as a result of an
expanding lesion
Headaches
• Etiology/Pathophysiology
– Skull and brain tissues are not able to feel sensory
pain
• Pain arises from the scalp, blood vessels, muscles,
dura mater, and sinuses
– Vascular Headaches
• Migraine
– Vessels are dilated
• Hypertensive
– Excessive pressure
– Tension Headaches
• Psychological problems
– tension, stress,
• Cervical arthritis
– Traction-Inflammation Headaches
• Infection, intracranial or extracranial causes, occlusive
vascular structures, temporal arteritis
Headaches
• Signs & Symptoms
– Head pain
– Migraine headaches
• Prodromal (early s/s)
– visual field defects, experiencing unusual smells or
sounds, disorientation, paresthesias, and rarely
paralysis of a part of the body
• During headache
– nausea, vomiting, light sensitivity, chilliness, fatigue,
irritability, diaphoresis, edema
Headache
• Treatment
– Diet
• Limit MSG, vinegar, chocolate, yogurt, alcohol, fermented
or marinated foods, ripened cheese, cured sandwich
meat, caffeine, and pork
– Psychotherapy
• Decrease stress factors
– Medications
• Migraine Headaches
– aspirin, acetaminophen, ibuprofen
– ergotamine tartrate
» Constricts vessels
– Codeine
– Inderal
Headaches
• Tension Headaches
– Nonnarcotic analgesics
» acetaminophen, propoxyphene, phenacetin,
ibuprofen, and aspirin
• Traction-inflammatory Headaches
– Treat cause
– Comfort Measures
• Cold packs to forehead or base of skull
• Pressure to temporal arteries
• Dark room; limit auditory stimulation
Increased Intracranial Pressure
• Etiology/Pathophysiology
– Increase in any content of the cranium
• Cranium is rigid and nonexpandable
– Space-occupying lesions, cerebrospinal
problems, cerebral edema
Increased Intracranial Pressure
• Signs & Symptoms
– Diplopia
• double vision
– Headache
• increases with coughing, straining, or stooping
– Decrease in level of consciousness
• disorientation, restlessness, lethargy
– Pupillary signs
• ipsilateral pupil dilation
– lesion is one hemisphere
• bilateral pupil dilation
– both halves of brain are involved
Increased Intracranial Pressure
– Widening pulse pressure
• increased systolic and decreased diastolic B/P
– Bradycardia
– Respiratory problems
• vary related to the level of brainstem
involvement
– High, uncontrolled temperatures
– Positive Babinski’s reflex
• Toes fan out when bottom of foot is stroked
– Seizures
Increased Intracranial Pressure
– Posturing
• decorticate
– flexion of arms, wrists, and fingers with adduction of
arms
• decerebrate
– All four extremities in rigid extension, with
hyperpronation of forearmsand plantar extension of
feet
– Vomiting
– Singultus
Increased Intracranial Pressure
• Treatment
– Treat cause if possible
– Mechanical decompression
• Craniotomy
– remove bone flap and replace
• Craniectomy
– remove bone flap and not replaced
– Internal Monitoring Devices
• Diagnose and monitor increased intracranial pressure
• Ventricular catheter, subarachnoid bolt or screw, and the
epidural sensor
– produce pressure waves to indicate status of IIP
Epilepsy or Seizures
• Etiology/Pathophysiology
– Transitory disturbance in consciousness or
in motor, sensory, or autonomic function
with or without loss of consciousness
– Sudden, excessive, and disorderly
discharges in the neurons of the brain
– Results in sudden, violent, involuntary
contraction of a group of muscles
– Hypoglycemia, infection, and electrolyte
imbalance.
Epilepsy or Seizures
– Types of seizures
• Grand Mal
– Generalized
– Tonic-clonic movements
– Loss of consciousness
• Petit Mal
– Sudden impairment or loss of consciousness
– Little or no tonic-clonic movement
– Vacant facial expression; eye straight ahead
• Psychomotor
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Sudden change in awareness
Behaves as if partially conscious
May appear intoxicated
Antisocial behavior
» exposing self or violence
Epilepsy or Seizures
• Jacksonian-focal
– One body part is affected
» hand, foot, face
– May end in grand mal seizure
• Myoclonic
– Sudden involuntary contraction of muscle group
» usually in extremities or trunk
– No loss of consciousness
• Akinetic
– Generlaized tonelessness
– Falls in flaccid state
– Unconsciousness for 1-2 minutes
Epilepsy or Seizures
• Signs & Symptoms
– Depends on type of seizure
– Aura
• Sensation that may precede a seizure
– flashing lights, smells, numbness, tingling,
hallucinations
– Postictal Period
• Rest period of variable length
• Groggy and disoriented
• Headache and muscle aches
• May sleep
Epilepsy or Seizures
– Status epilepticus
• recurrent, gernalized seizure activity occurs at
such frequency that full consciousness is not
regained
Epilepsy or Seizures
• Treatment
– During seizure
• Protect from aspiration and injury
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Lower to the floor
Move away from furniture and equipment
Turn the head to the side if possible
Loosen clothing around neck
DO NOT RESTRAIN
DO NOT PUT ANYTHING IN MOUTH
– Medications
• Page 608; table 15-5
– Surgery
• Removal of brain tissue where seizure occurs
Epilepsy or Seizures
– Adequate rest
– Good nutrition
– Avoid alcohol
– Avoid driving, operating machinery, &
swimming until seizures are controlled
– Good oral hygiene esp. if on Dilantin
• causes gingival hyperplasia
– edematous and enlarged gums
– Medical alert tag
Multiple Sclerosis
• Etiology/Pathophysiology
– Degenerative neurological disorder
– Cause unknown
– Possibly genetic
– Most common in wet cold climates
– Demyelination of the brain stem, spinal
cord, optic nerves, and cerebrum
• causes an interruption or distortion of the nerve
impulse
Multiple Sclerosis
• Signs & Symptoms
– Visual problems
• diplopia
• scotomata (spots)
• blindness
• nystagmus
– Urinary incontinence
– Fatigue
– Weakness
– Incoordination
– Sexual problems
– Swallowing difficulties
Multiple Sclerosis
– Remissions may last for a year or more
– Exacerbaions precipitated by
• fatigue
• chilling
• emotional disturbances
Multiple Sclerosis
• Treatment
– No specific treatment
– Adrenocorticotropic hormone (ACTH)
– Steroids
• prednisone
– Deltasone or Decadron
– Valium
– Betaseron (Interferon beta-1b)
• reduces frequency of exacerbations
– Avonex (Interferon beta-1a)
• reduce neurological attacks and slow progress
of physical disability
Multiple Sclerosis
– Pro-Banthine
• decrease urinary frequency and urgency
– Urecholine
• antispasmodic for neurogenic bladder
– Bactrim, Septra, & Macrodanitn
• Urinary tract infections
Parkinson’s Disease
• Etiology/Pathophysiology
– Deficiency of dopamine
• necessary for the normal transmission of nerve
impulses
– Viral, toxic, vascular and genetic causes
– May be drug induced
• Reserpine, phenothiazines, haloperidol, cocaine
Parkinson’s Disease
• Signs & Symptoms
– Muscular tremors
– Rigidity
• mask-like facial appearance
• monotonous speech
• drooling
– Propulsive gait
– Emotional instability
– Heat intolerance
– Decreased blinking
– “Pill-rolling” motions of fingers
– Bradykinesia
• slowness of voluntary movements and speech
Parkinson’s Disease
Parkinson’s Disease
• Treatment
– Medications
– side effects may be worse than disease
• Levodopa
– converted to dopamine
• Sinemet
• Artane
• Cogentin
• Symmetrol
– Surgery
• Pallidotomy
– Destroying portions of the brain that control the
rigidity or tremor
• Human fetal dopamine cell transplants
Alzheimer’s Disease
• Etiology/Pathophysiology
– Impaired intellectual functioning
– Degeneration of the cells of the brain
– Cause is unknown
– Possible genetic link
Alzheimer’s Disease
• Signs & Symptoms
– Early Stage
• Mild memory lapses
• Decreased attention span
– Second Stage
• Obvious memory lapses
– Esp. short term
– Disorientation to time
– Loss of personal belongings
– Third Stage
• Total disorientation to person, place, & time
• Apraxia
– impaired ability to perform purposeful acts or use objects
• Wandering
– Terminal Stage
• Severe mental and physical deterioration
Alzheimer’s Disease
• Treatment
– Medications
• Agitation
– Lorazepam
– Haldol
• Dementia
– Cognex
– Aricept
– Nutrition
• Finger foods
• Frequent feedings
• Encourage fluids
Alzheimer’s Disease
– Safety
• Removing burner controls at night
• Double-locking all doors and windows
• Constant supervision
Myasthenia Gravis
• Etiology/Pathophysiology
– Neuromuscular disorder
– Nerve impulses fail to pass at the myoneural junction; causes muscular weakness
– Possible causes
• Inadequate production of acetylcholine
• Excessive quantities of cholinesterase
• Non-response of the muscle fibers to
acetylcholine
Myasthenia Gravis
• Signs & Symptoms
– Ocular
• Ptosis
– eyelid drooping
• Diplopia
– double vision
– Generalized
• Skeletal weakness
• Dysarthria
• Dysphagia
• Ataxia
• Bowel and bladder incontinence
Myasthenia Gravis
• Treatment
– Anticholinesterase drugs
• Prostigmin
• Mestinon
– Corticosteroids
– May require mechanical ventilation
Amyotrophic Lateral Sclerosis (ALS)
Lou Gehrig’s Disease
• Etiology/Pathophysiology
– Motor neurons in the brainstem and spinal
cord gradually degenerate
– Electrical and chemical messages
originating in the brain do not reach the
muscles to activate them
Amyotrophic Lateral Sclerosis (ALS)
Lou Gehrig’s Disease
• Signs & Symptoms
– Weakness of the upper extremities
– Dysarthria
– Dysphagia
– Muscle wasting
– Compromised respiratory function
• death usually occurs due to infection
Amyotrophic Lateral Sclerosis (ALS)
Lou Gehrig’s Disease
• Treatment
– No cure
– Rilutec (riluzole)
• Helps protect damaged motor neurons
– Multidisciplinary ALS Teams
• experimental drugs
• physical, occupational, and speech therapy
• nutritional regimens
• psychological support
– Emotional support
• Mentally healthy; physically wasting away
Huntington’s Disease
• Etiology/Pathophysiology
– Overactivity of the dopamine pathways
• opposite of Parkinson’s
– Genetically transmitted
Huntington’s Disease
• Signs & Symptoms
– Abnormal and excessive involuntary
movements (chorea)
• Writhing, twisting movements of the face,
limbs, and body
• Abnormal facial movements
– affect speech, chewing, and swallowing
– Ataxia to immobility
– Deterioration in mental functions
Huntington’s Disease
• Treatment
– No cure; pallative treatment
– Antipsychotics
– Antidepressants
– Antichoreas
– Safe environment
– Emotional support
– High calorie diet
Cerebral Vascular Accident (CVA)
• Etiology/Pathophysiology
– Abnormal condition of the blood vessels of
the brain
• thrombosis
• emoblism
• hemorrhage
– Results in ischemia of the brain tissue
– Underlying causes
• atherosclerosis, heart disease, hypertension, kidney
disease, PVD, DM
– Risk factors
• obesity, high serum cholesterol, cigarette smoking,
stress, cocaine use, and sedentary lifestyle
Cerebral Vascular Accident (CVA)
• Signs & Symptoms
– Headache
– Sensory deficit
• numbness or tingling
• inability to think clearly
• visual problems
– Hemiparesis
• Weakness on one side of the body
– Hemipalegia
• Paralysis on one side of the body
• Depends on area of brain affected
– Dysphasia or aphasia
Cerebral Vascular Accident (CVA)
• Treatment
– Aneurysm
• Surgery
– tie off or clipping of aneurysm
– Thrombosis or Embolism
• Thrombolytics
– TPA, activase
• Heparin and Coumadin
– Decadron
– Neurological checks
– Feeding tube
– Physical, occupation, and/or speech therapy
Trigeminal Neuralgia
(Tic Douloureux)
• Etiology/Pathophysiology
– Degeneration of or pressure on the
trigeminal nerve
Trigeminal Neuralgia
(Tic Douloureux)
• Signs & Symptoms
– Excruciating, burning pain
• radiates along one or more of the three
divisions of the fifth cranial nerve
– typically extends only to the midline of the face and
head
• pain may be initiated by stimulation of “trigger
points”
Trigeminal Neuralgia
(Tic Douloureux)
• Treatment
– Tegretol
– Surgical resection of the trigeminal nerve
– Avoid stimulation of face on affected side
• touching
• drafts
• hot or cold liquids
Bell’s Palsy
(peripherial facial paralysis)
• Etiology/Pathophysiology
– Inflammatory process involving the facial
nerve
– Vasoconstriction due to ischemia, edema,
or emotional trauma may also be a cause
– Unilateral or bilateral
Bell’s Palsy
(peripherial facial paralysis)
• Signs & Symptoms
– Facial numbness or stiffness
– Drawing sensation of the face
– Unilateral weakness of facial muscles
• unable to wrinkle forehead, close eyelid, pucker lips, or
retract the mouth
• Face appears asymmetric
– drooping of mouth and cheek
– Loss of taste
– Reduction of saliva
– Pain behind the ear
– Ringing in ear or other hearing loss
Bell’s Palsy
Bell’s Palsy
(peripherial facial paralysis)
• Treatment
– Electrical stimulation
– Warm moist heat
– Steroids
– Massage of the affected area
– Exercises
• wrinkling the brow and forehead, closing the
eyes, and puffing out the cheeks.
Guillain-Barre’ Syndrome
• Etiology/Pathophysiology
– Inflammation and demyelination of the
peripheral nervous system
– Cause is unknown
– Possibly viral or autoimmune reaction
Guillain-Barre’ Syndrome
• Signs & Symptoms
– Symptoms are progressive
– Progression may stop at any point
– Paralysis usually starts in the lower
extremities and moves upward
– May include the thorax, upper extremities,
and face
– Respiratory failure if intercostal muscles
are affected
– May have difficulty swallowing, breathing,
and speaking
Guillain-Barre’ Syndrome
• Treatment
– Adrenocortical steroids
– Apheresis
• removal of unwanted components from the
blood serum by a flow separator
– Mechanical ventilation
• may require tracheostomy
– Gastrostomy tube
– Meticulous skin care
– Range of motion exercises
Meningitis
• Etiology/Pathophysiology
– Acute infection of the meninges
– Pneumococci, meningococci, staphylococci,
streptococci, H. influenzae, and viral
– Bacterial or aseptic
Meningitis
• Signs & Symptoms
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Headache
Stiff neck
Irritability
Malaise
Restlessness
Nausea & vomiting
Delirium
Elevated temperature, pulse, & respirations
Kernig’s Sign
• inability to extend the legs completely without extreme
pain
– Brudzinski’s Sign
• flexion of the hip and knee when the neck is flexed
Meningitis
• Treatment
– Antibiotics
• massive doses
• multiple types
• IV or intrathecal
– Steroids
– Anticonvulsants
– Dark, quiet room
• stimulation may cause seizure
Intracranial Tumors
• Etiology/Pathophysiology
– Benign or malignant
– Primary or metastatic
– May affect any area of the brain
Intracranial Tumors
• Signs & Symptoms
– Headache
– Hearing loss
– Motor weakness
– Ataxia
– Decreased alertness and consciousness
– Abnormal pupil response and/or unequal
size
– Seizures
– Speech abnormalities
Intracranial Tumors
• Treatment
– Surgical removal of tumor
• craniotomy
• intracranial endoscopy
– Radiation
– Chemotherapy
– Combination of above
Crainiotomy
Craniocerebral Trauma
(Head Injury)
• Etiology/Pathophysiology
– Motor vehicle and motorcycle accidents,
falls, industrial accidents, assaults, and
sports trauma
– Direct trauma
• head is directly injured
• acceleration-deceleration injury
• bruising or contusion of the occipital and frontal lobes
and brainstem and cerebellum
– Indirect trauma
• Tension strains and shearing forces transmitted to the
head by stretching of the neck
Craniocerebral Trauma
(Head Injury)
– Open head injuries
• Skull fractures
• Penetrating wounds
– Closed head injuries
• Concussions
– violent jarring of the brain against the skull
• Contusions
• Lacerations
– Hematomas
• scalp, epidural, subdural, intracerebral, and
intraventricular
– epidural and subdural must be monitored carefully
Craniocerebral Trauma
(Head Injury)
• Signs & Symptoms
– Headache
– Nausea
– Vomiting
– Abnormal sensations
– Loss of consciousness
– Bleeding from ears or nose
– Abnormal pupil size and\or reaction
– Battle’s Sign
• in small hemorrhagic spot behind the ear
• may indicate a fracture the lower skull
Craniocerebral Trauma
(Head Injury)
• Treatment
– Maintain airway
– Oxygen
– Mannitol and dexamethasone
• reduce cerebral edema and IICP
– Analgesics
• must not suppress respiratory system
– Anticonvulsants
Spinal Cord Trauma
• Etiology/Pathophysiology
– Automobile, motorcycle, diving, surfing,
other athletic accidents, and gunshot
wounds
– Fracture of vertebra
• simple, compressed, wedged, comminuted or burst
fractures
• dislocation of vertebrae
– Complete cord injury
• total transection of the spinal cord
• complete loss of spinal cord function
– Incomplete cord injury
• partial transection or injury of spinal cord
Spinal Cord Trauma
• Signs & Symptoms
– Loss of muscle function depends on level
of injury
• INJURY
• Above C4
• C5
• C6-C7
• Thoracic
• Lumbosacral
LOST FUNCTION
All, including respiration
Arms, chest, all below chest
Some arm, fingers, chest, all
below chest
Trunk, all below chest
Legs
Spinal Cord Trauma
– Spinal Shock
• Vasodilation, increased venous capacity, and
hypotension
– Autonomic dysreflexia
• Increased reflex actions
– bradycardia, hypertension, diaphoresis, “goose
bumps”, severe headache, and nasal stuffiness
• Occurs in injuries above T6; most common in
cervical injuries
• Result of abnormal cardivascular response to
stimulation of the sympathetic division of the
autonomic nervous system
• Occurs as a result of stimulation of the bladder,
large intestine or other visceral organs
Spinal Cord Trauma
– Sexual Dysfunction
• Male
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Impotence
Decreased sensation
Difficulties with ejaculation
Infertility
• Female
– Altered sexual pleasure
Spinal Cord Trauma
– Treatment
• Realignment of bony column for fractures or
dislocations
– Immobilization
– Skeletal traction
» Crutchfield tongs
» Halo traction
» Stryker frame
– Sugery for spinal decompression
• Methylprednisolone
– high doses
Spinal Cord Trauma
– Mobility
• Slowly increase sitting up
– may have to use thromboembolism stockings
– prevents hypotension
• Urinary function
– Foley catheter, initially
– Bladder training
– Intermittent catheterization
• Bowel function
– Bowel program
» Dulcolax suppositories
» Digital stimulation
» Adequate fluids
» Stool softeners