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Med-Surg I
Chp. 45 Interventions for Cts w/ Probs of the CNS: the brain III
| Question | Answer |
|---|---|
| Infections; Meningitis | Inflammation of the arachnoid and pia mater of brain and spinal cord and the cerebrospinal fluid (CSF) |
| Types of Meningitis | Bacterial, Protozoal, and Fungal (Regardless of the type symptoms are the same) |
| Bacterial Meningitis | most frequent meningitis, early detection and treatment associated w/better outcome. |
| Viral Meningitis | self-limiting, and ct has a complete recovery; not considered life threatening; |
| Viral Meningitis | most common type of meningitis, sometimes refered to as aseptic meningitis; sequela to a variety of viral illnesses, including measles, mumps, herpes simplex, and herpes zoster |
| Bacterial meningitis | medical emergency with a mortality rate of about 25%. Most frequent organisim responsible are Streptococcus pneumoniae and Neisseria meningitidis |
| Meningitis Physical Manifestations | headache, N&V, fever; complaint of photophobia and have indications of increased intracranial pressure; stiff neck and possitvie Kernig's adn Brudzink's signs; seizure, decreased mental status, or focal neurologic deficits(bacterial menigitis) |
| Meningitis Lab Assessment | MOST SIGNIFICAT LAB CSF; clients older than 60 yrs of age, immunocompromised or have increased ICP have a CT performed; blood culture and sensitivity and a broad-spectrum antibiotic given before lumbar puncture |
| Meningitis Lab Assessment; Counterimmunoelectrophoresis (CIE) | determines presence of viruses or protozoa in CS; indicated if ct has received antibiotics before the CSF was obtained; gram stains of blood, urine, throat, and nose are performed (bacterial) |
| Meningitis Lab Assessment; Polymerase chain reaction (PCR) | used to detect viral deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) in CSF; encephalitis, herpes simplex virus; rapid and noninvasive, replases brain biopsy for diagnosis |
| Meningitis Lab Assessment; CBC | attention to WBC count, serum electrolyte values are assessed w/ attention to sodium, dilutional hyponatremia may occur secondary to SIADH (complication of bacterial meningitis) |
| Meningitis Lab Assessment; other assessments | X-rays of the chest, air sinuses, and mastoids obtained to determine presence of infection, CT or MRI to identify ICP, brain abscess, or developing hydrocephalus |
| Meningitis Drug Therapy | Broad-spectrum antibiotic until results of culture aond Gram stain are avaliable; hyperosmolar agents and anticonvulsants to treat complications; |
| Meningitis Drug Therapy; Prophylaxis | controversy over giving steroids but it is recommended for ct's with S. pneumoniae; those who have been in close contact w/ a ct who has N. meningitides receives rifampin, ciprofloxacin, or ceftriaxone |
| Meningitis Drug Therapy; Prophylaxis | rifampin for someone who has been in close contact w/ a ct who has H. influenze meningitis |
| Encephalitis; Pahto | inflammation of the brain parencheyma (brain tissue) and the meninges; affects the cerebrum, brainstem, and cerebellum; mostly caused by a viral agent, bacteria, fungi, or parasites may be involved (Malaria). |
| Encephalitis | iflammation extends over the cerebral cortex, the white matter, and meninges, causeing degenration of the neurons of the cortex. Demyelation of axons white matter is distroyed; leads to hemorrhage, edema, necrosis |
| Encephalitis | development of small lacunae (hollow cavities) witin the cerebral hemipheres |
| Arboviruses | transmitted to humans thru the bite of an infected mosquito or tick (west nile virus) |
| Enteroviruses | echovirus, coxsackievirus, poliovirus, herpes zoster, and viruses that cause mumps and chickenpox are the most common enteroviruses associated w/ encephalitis |
| Herpes Simplex Virus Type 1 | most common nonepidemic type of encephalitis in North America, Ct usually have a history of cold sores |
| Amebae | caused by the amebae Naegleria and Acanthamoeba; found in warm freshwater areas adn can enter the nasla mucosa of people swimming in ponds and lakes; also found in soil and decaying vegetation |
| Encephalitis Interventions | 1. Prompt recongition and treatmetn of cerebral edema, hemorrahage, necrosis of brain tissue; 2. establish patient airway; 3. assessment of vital signs every 2hrs; 4. continuous supportive care and assessment |
| parkinson disease | debilitating disease affecting motor ability and characterized by four cardinal symptoms: tremor, rigidty, akinesia (slow movement), and postural instability |
| parkinson disease; etiology and genetic risk | exact cause unkown, may be due to genetic and envoirnmental factors (endotoxin (lipopolysaccharide [LPS]) a common airborne contaminate in agriculture and other industries, rural living, well water consumption, and living near wood pulp mills |
| parkinson disease; etiology and genetic risk | gene mutation some cts w/ PD have an extra copy of a normal gene(alpha-synuclein) which causes too much protien build uo in ther brains |
| Stage 1: Initial Stage of Parkinson disease | Unilateral limb involvement; minimal weakness, hadn and arm trembling |
| Stage 2: Mild Stage of PD | Bilateral limb involvement; masklike facies; slow, shuffing gate |
| Stage 3: Moderate Disease of PD | Increase gait disturbances |
| Stage 4: Severe disability of PD | Akinesia; rigidity |
| Stage 5: Complete Dependence of PD | Complete Dependence of PD |
| PD assessment | Older adult may assume that Parkinson's behaviors are normal changes associate w/ aging, and may ignore early signs and sympt.; such as fatigue, slight tremor, and problems w/ manual dexterity |
| PD assessment | masklike faces w/ wide-open, fixed, staring eyes are caused by rididity of the facial muscles; rigidity can lead to difficulties in chewing and swallowing, particularly if pharyngeal muscles are involved, causing inadequate nutrition |
| PD assessment | uncontrolled drooling, dementia later as disease progresses, voluntary movement, excessive perspiration and orthostatic hypotention |
| PD diagnosis | made on the basis of the clinical findings after neurologic diseases are eliminated as possibilites; no specific diagnostic tests/ CSF may show decreased dopamine levels |
| PD drug therapy Anticholinergic drugs | = for primary sympt. of tremor; Amantadine (Symmetrel) prescribed for younger ct's w/ tremor as main problem |
| PD drug therapy Dopamine agonists= | stimulate dopamine receptors and r most effective during first 3-5 yrs of use; benefit=less frequent incidents of dykinesias (problems w/ movement); SE: Nausea, Postural hypotension, hallucinations, and drowsiness |
| PD drug therapy Levodopa (Dopar, L-dopa)= | combination w/ carbidopa (Sinemet) most effective treatment; given when ct presents symptoms of severe or interfer w/ work or school |
| PD drug therapy bromocriptine mesylate | proscribe early in the course of treatment; useful in ct who has experienced side effects suchas dyskinesia or orhtostatic hypotension while receiving Sinemet |
| PD drug therapy Amantadine (Symmetrel) | antiviral drug that hs anti-parkinson benefits also perscribed w/ Sinement to reduce dyskinseias and treats symptomsof "wearing off" |
| Newer parkinson drugs O-methyltransferae (COMT) inhibitors | inhibitors block the breakdown of levodopa in the body so more can travel to brain and convert to dopamine. Used in conjuction w/ Sinemet and help prevent "wearing off" periods |
| Drug Toxicity for PD (Compare ct's current cognitive and behavioral status w/ his or her baseline before) | those on long-term drug therapy, drug tolerance or drug toxicity often develops. Drug toxcitiy is evidenced by delirum (acute confusion), cognitive impairment, decreased effectiveness of the drug or hallucinations |
| Drug Toxicity for PD | when drug tolerance is reached , the drug's efects do not last as long as previously |
| Drug Toxicity for PD Treatment | reduction in med dosage, change of meds or frequency of admin., DRUG HOLIDAY! particularly w/ levadopa therapy lasts up to 10 days= ct receives no meds |
| Exercise and ambulation for PD | yoga, tai chi may elevate mood and improve mobility in early stages, PT and OT for active and passive ROM exercises, muscle stretching, and activity; Ct is instructed to AVOID watching his or her feet when walking to prevent falls |
| Self Care for PD | Participate in ADLs, training in ADLs from PT and OT (OT may determine need for special eating utensils) |
| Nurtrion for PD | registered dietitian evlauates ct's food intake (vita. K, and calcium), or has difficulty swallowing. Soft diet or thick, cold fluids, such as milk shakes are easily tolerated, liquid thickners added to liquids |
| Communication for PD | ST teaches ct exercises to strengthen muscles used for breathing, speech, and swallowing; Ct is instructed to speak slowly and clearly and to pause and take deep breaths at appropriate intervals during each sentence. |
| Psychosocial support for PD | Those ct who feel ashamed of their condition should be encouraged to undertake activities that do not requere small muscel dexterity, such as light, modified aerobic exercises |
| Surgical Management for PD; stereotactic pallidotomy | controls symptoms associated w/ PD, CT or MRI finds target areal within the pallidum, next sterotatic head fram is placed on the ct, iv sedation, burr hole made in cranium, electrode or cylindric rod inserted into target area |
| Surgical Management for PD/ thalamotomy | alternative to sereotatic pallidotomy, for treatment of tremor thru thermocoagualtion of brain cells |
| Surgical Management for PD; deep brain stimulaton | a thin electrode is implanted in the thalamus or subthalamus and then connected to the pacemaker that delivers electrical current to interfere w/ tremor cells. Electrodes are connected to an implantable pulse generator similar to a cardiac pacemaker |
| Surgical Management for PD; Fetal Tissue Transplantation | fetal substantia nigra tissue, either human or pig, is transplanted n to the caudate nucleus of the brain. Reports suggests that cts have a substantial clinical improvement in motor symptoms w/out dyskinesias after receiveing transplant tissue |
| Alzheirmer's disease (AD) Patho | aka dementia, chronic, progressive, degenerative, disease that accounts for 60% of the demetnias occuring in people older than 65yrs old |
| Alzheirmer's disease (AD) Patho | loss of memory, judgmen, and visuospatial perception, and change in personality, increasingly cognitively impaired, severe physical deteroration takes place and death occurs as a result of complications of immobility |
| Alzheirmer's disease (AD) Patho; Structual changes in the brain; Neurofibrillary tangles: | classic finding at the autopsy in the brains of clients with AD |
| Alzheirmer's disease (AD) Patho; Structual changes in the brain; senile or neuritic plaques | composed of degenerating nerve terminals and are foudn particualarly n the hippocampus, an important part of limbic system |
| Alzheirmer's disease (AD) Patho; Structual changes in the brain;beta amyloid | increased amounts of abnormal protien depositied within the plaques |
| Research of AD is focusiing on: | does beta amyloid disrup the normal sodium, potassium, and calcium channels responsible for nerve function and signal transmission; how does overprodution of oxidants affect genetic material in DNA cells |
| Research of AD is focusiing on: | what is the role of overproduction of immune factors in response to oxidation in the development of AD? |
| Vascular Degeneration of the the brain is significantly increased in Cts w/ this disease | AD |
| Chemical changes in the Brain: Abnormalities in these neruotransmitters | acetylecholine, norepinephrine, dopamine, seritonin; high levels of beta amyloid associated w/ reduced acetylcholine (exact role of reduction of neurotransmitters in the development of AD is not well understood) |
| Stages of AD: Stage I (Ct may not necessarily progress from one stage to the next; they may exhibit symptoms of one or several stages) | forgets names; misplaces household itemsmild memory loss; short attention span; no social or employment probs; wandering; decreased sense of smell |
| Stages of AD: Stage II | severe impairment of all cognitive functions; complete disorientation to time, place, and event; possible depression and agitated; loss of ability ot care for self; incontinent; speech and lange deficits |
| Stages of AD: Stage III | Completely incapacitated; totally dependent in ADLs; motor and verbal skill loss; general and focal neurologic deficits |
| Physical assessment/clinical manifestations of AD; Where is the damage in the brain? | Frontal lobe impairment: produces difficuties w/ judgement, inability to make decisions, decreased attention span, and diminished ability to concentrate |
| Physical assessment/clinical manifestations of AD; Changes in congniton | Communication and language: apraxia (inability to use objects approbriately); aphasia (inability to speak or understand); anomia(inability to find words); agnosia(loss of sensory comprehension) all due to dysfucntion of the temporal and parietal lobes |
| To Assess the presense of cognitive impairment the nurse would use these tools.. | Fostein's Mini-Mental State Examination (MMSE); the mini-mental assess five major areas; orientation, registration, attention adn calculation, recall and speech-language (reading too). Score 0-30/ the lower the score the greater the demetnia |
| To Assess the presense of cognitive impairment the nurse would use these tools.. | SET test for those who can not read or are older...asked to name 10 items in 4 catagories, 40 possible points. score of 25 means NO dementia |
| Changes in Behavior and personality AD | CT is assessed for aggressivensess (verbal and pysical abusive tendencies); rapid mood swings; increased confusion at night (sundowning) |
| A Ct with AD may experience this... | paranoia, delusions, hallucinations, and depression |
| Changes in self-care skills AD | decreased, interest in personal appearance; selection of clothing that is inappropriate for the wheater or event; loss of bowel and bladder control; decreased appetite or abiltity to eat; muscle contractures develop; becomes totally immobile |
| Psycohsocial assessment AD | in early stages Ct may recognize that they are experiencing memory or cognitive changes, may attempt to hide problems, deny them or become depressed over the changes; think it's becasue of "old age" |
| Psycohsocial assessment AD MOST IMPORTANT TO ASSESS THIS REACTION! | THE CLIETNS REACTION TO CHANGES IN ROUTINE OR ENVIORNMENT ex: Ct is admitted to the hospital, they overreact and become aggressive or abusive |
| Inteventions AD | Ct needs a structured and consistent enviornment; Cognitive stimulation/ memory training: reinforces desirable cognitive function adn facilitate memory; |
| Inteventions AD Structuring the Envoirnment: prevent overstimulation and provide a structured enviornment | keep enviornmental distractions and noise to a minimum, pics of people or anmimals that could harm them should not be on the walls, adequate lighting; to avoid distrubed sleep provide adequate nutritional intake, televison should remain off |
| Inteventions AD Providing Consistancy | objects such as furnitrue, hairbrush, and eyeglasses should be kept in the same place; daily routine; communication board that has days of the week, activities, and pics of familiar peps should be on a board in ct'room |
| Inteventions AD Orientation and Validation Therapy | expain changes in routine before they occur, reality orientation (remind the ct of their enviornment); Validation therapy (for Cts in late stages of AD) ex: ct is looking for a deceased mother, ask ct what the mother looks like (play along) |
| Inteventions AD Promoting Independence in Activities of Daily Living | Encourage ct to perform as much self care as possible; ex: ct completes clothing outfits that can be easily removed and put on (shirt, pant, underware, socks); help w/ meal preparation, and grocery shopping |
| Inteventions AD Bowel and Bladder Continence | take ct to bathroom or give bedpan every 2hrs or more often during the day, may use the bathroom less during the night if this is done; drink adquate fluids to promote voiding; place pic of toilet on bathroom door as a reminder of where to use the pot! |
| Prosopagnosia | inability to recognize oneself and other familiar faces; intervention: provide family pics, and family reminisce w/ ct about pleasent experiences |
| Inteventions AD Promoting Communication | Sentences should be clear and short! |
| Inteventions AD Drug Therapy; Cholinesterase inhibitors donepezil (Aricept) | improve cholinergic neurotransmision in the CNS, by delaying the destruciton of acetylcholine and delays the onset of cognitive decline. |
| Inteventions AD Drug Therapy;Memantine (Namenda) | new medication that is a low to moderate affinity NMDA (N-methyl D-aspartate) receptor antagonist *overexcitation of NMDA receptors by glutomate may play a role in AD*; this drug blocks excess amounts of glutamate that can damage nerve cells |
| Risk for Injury AD; coping w/ restliessness and wandering | always wear ID badge; that includes caregiver's name and contact info; ct placed in room close to nurse's station and away from stairs and exits; take ct for frequent walks and restlessness may be decreased; play games and puzzles w/ ct |
| Ensuring safety for AD cts | secure car keys, knives, needles, and cleaning solutions, so they wont take them; late in the disease the ct may experience seizure activity teach cargiver seizure interventions |
| Minimizing agitation for AD cts | talking calmly and softly and attemtpingot redirec the ct to a more positive behavior or activity may help when they are agitated ex:"I'm sorry that you are upset. I know it's hard. I will stay until you feel better." PROVIDE DIVERSION |
| Compromised family coping/caregiver role strain AD | family is expected to have a positive perception of their health status and life circumstances |
| Compromised family coping/caregiver role strain AD Interventions | Family seeks legal counsel regarding ct's competency and the need to obtain guardianship or durable medical power of attorney; be aware of their own health and stress levels |
| Distrubed Sleep Patterns for AD Interventions | difficulty sleeping at night but tends to nap frequently during the day; keep ct active during the day (walking stretching); establish before-bedtime ritual (personal hygiene activities); if this doesn't work dr. may prescribe antianxiety agent/hypnotic |
Created by:
prettydee1908
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