CRRN-Functional Health Patterns p. 13-130

Dysphagia card #1

Neurological disease linked to poor deglutition -Poor deglutition (dysphagia) is highly associated w/ having a CVA, particularly a brainstem CVA -Deglutition phase affected is r/t side where stroke occurred, w/injury to L & R hemispheres causing oral or pharyngeal phase impairments respectively -People with ALS typically have oral preparatory or pharyngeal issues such as poor tongue, poor tongue mobility, & incomplete chewing or impaired pharyngeal motility & peristalsis & aspiration respectively -Patients w/ Parkinson's have problems w/ all stages of swallowing starting w/ oral phase -Multiple stage deficits are common with most neuromuscular diseases including head traumas, multiple sclerosis, & myasthenia gravis -Cerebral palsy is primarily linked to a poor suck & other unsuitable reflexes during oral prep phase -Anatomical variations that can cause poor deglutition, such as cleft palates or lips & muscular pouches near cricopharyngeal muscle -Surgery or tubes in the area can also affect swallowing ability Diagnostic tests -Universal test for ID of dysphagia is bedside swallow exam (BSE); medical professional places 4 fingers (not thumb) on submandibular area, hyoid bone, thyroid notch, & cricoid cartilage while patient swallows to see whether tongue & larynx moves up & forward -More detailed analysis can be obtained by doing either a video flouroscopic (VFSS) or video endoscopic (VEES) swallow study --VFSS: person ingests barium-containing mixture & eating/swallowing process is videotaped --VEES: fiber optic nasopharyngoscope is used to observe deglutition (dye inhanced) of normal secretions, fluids, & foods of various consistencies; also know as fiberoptic endoscopic swallow study (FEES) & sensory differences are also evaluated by injecting air-pulsed stimuli through endoscope -Manometry: dx abnl peristaltic patterns in pharynx & esophagus through insertion of pressure measurement transducers Nursing dx, interventions, & outcomes -3 main areas: airway issues, nutritional deficits, & impaired swallowing -If determined to be risk for aspiration or has failed airway clearance-nurse's role is to initiate safety measures against possible aspiration & swallowing therapy -If pt not receiving adequate nutrition to meet body requirements, should begin nutritional therapy to improve nutritional status & intake of foods, fluids, & nutrients -If can't swallow properly, should take aspiration precautions & initiate swallowing therapy to improve swallowing status or oral, pharyngeal, & esophageal stages -If have eating or deglutition problems, may have other issues that need to be documented & addressed such as impaired ability or inability to perform self-care & ADLs

Correct Positioning During Defecation

-Should be seated during defecation to facilitate process; is recommended to have pt sit in squat position in which knees are a little above hips & feet are completely on floor; this position puts pressure on abdomen & also lines up rectum & anus -If have weak abdominal muscles, binders, massage to area, or breathing exercise can be used to increase pressure to area -Use of bedpans during process is not advocated unless absolutely necessary, & then pt should be weaned from using them; an incontinence pad may be used for patients w/skin issues or those who have lost sensation in buttocks region

Gerontological rehabilitation card #4

Chronic Confusion -Also known as dementia & cognitive & intellectual deterioration -Dementia: protracted & progressive; characteristics: personality changes, disorientation, & mood swings, impairments in both short- & long-term memory, disturbed thought processes & judgment, and chronic abnl sleep patterns -Demented patient: socially inept, unable to perform ADLs, may make up fictitious memories -Associated with a variety of neurological disorders-Alzheimer's, dementia pugilistica (frontal lobe impairment d/t head injuries), ALS or Parkinson's, also induced by alcoholism (Wernicke's dementia), HIV or syphilis, toxic drug levels (benzos or methyldopa) -May be d/t underlying metabolic disorder (hypoglycemia or hypothyroidism), presence of intracranial mass, hydrocephalus, or cerebral infarcts (multiinfarct dementia); if underlying disease is treated, occasionally dementia is reversible Reactive Depression -A state of sadness, unhappiness, & hopelessness -Has some same symptoms of dementia, such as memory loss & disorientation & inability to concentrate; people in early dementia stages are often depressed -Other signs: lack of appetite, lack of appetite, lack of interest, & crying spells -Geriatric Depression Scale is useful assessment tool with scale >/=8 indicating possible depression -Usually occurs in response to some specific set of events, also can be caused by meds (hormones, chemotherapeutic drugs) -Life threatening if undiagnosed & untreated, elderly often do not acknowledge symptoms -Tx: antidepressants (SSRIs), psychotherapy, social involvement, exercise, focus on self-care -Nurses provide safe & stable environment Elder Abuse -Particularly seen in females with dementia, abused by caregivers -May be verbal, psychological, neglect -Physical signs: fractures, bruising, recoiling from touch -Neglect signs: malnutrition, dehydration, inadequate hygiene, unaddressed health issues, unsanitary living environment -Behavior patterns for verbal/psychological abuse: agitation, sucking or rocking, expressions of hopelessness & helplessness, conflicting feelings toward family members -If caregiver suspects abuse, must convey info to state or county department of Adult Protective Services (APS) or state office of child & family services; each case is then allocated a social worker & possibly a guardian

Drugs for burn (2nd or 3rd degree) treatment

Silver sulfadiazine 1% (Silvadene) -Apply ointment under sterile conditions 1-2x/day Mafenide (Sulfamylon) -Comes as 8.5% cream or powder that is mixed with SW or NS to a 5% solution -Apply 3-4x/day -Contraindicated for patients with sulfite allergies or kidney failure

Cardiac rehabilitation card #3

Risk Stratification for Exercise Participation -Cardiac risk assessment: age, gender (including female menopause status), tobacco use, physical activity, hx of HTN, nutritional status, psychosocial background (including depression), hostility level, & family hx -Specific tests: lipid profile, BMI, fasting blood glucose -Risk stratification: functional capacity, rest EF, CHF presence, evidence of arrhythmias, dyspnea, dizziness upon exertion; pt is then classified as low, intermediate, or high risk --Low: All risk factors such as angina & CHF are absent, functional capacity is >/= 7 METs, rest EF is >/= 50%, & MI or revascularization was uncomplicated --Intermediate: exhibit symptoms, some silent ischemia, < 5 METs, rest EF of 40-49% --High: further abnormalities Diagnoses for Early Outpatient Cardiac Rehab -Common to both inpatient and early outpatient: risk for activity intolerance, anxiety, deficient knowledge -Early outpatient settings: risk-prone health behavior, ineffective health maintenance, sexual dysfunction -Nurse is responsible to help manage symptoms, improve functional abilities, develop exercise tolerance, temper cardiac risk factors through lifestyle modifications --Include exercise program, weight management, lower cholesterol intake, cessation of smoking & ETOH use, stress & coping strategies, control of HTN & DM if present -Therapeutic objectives: cardiac care, rehab cardiac care, anticipatory guidance, anxiety reduction, education of patient & family about exercise program, disease process, risks, lifestyle modifications Outpatient Cardiac Rehab Exercise Program -Individualized prescriptions (comprised by exercise physiologist) for specific patients -Walking is most common; also arm ergometry, aquatic excercises, rowing, jogging, cycling, or low intensity weight training -Typical session: warm-up (stretching & ROM), conditioning, cool-down periods; time for each period is 5-15 minutes, 20-30 minutes, & 5-10 minutes; usually 3-5 sessions/week -Closely monitored by ECG during activity; terminated if DBP >/= 110 mm Hg or SBP rises more then 10 mm Hg, significant dysrhythmias, heart block, CP, SOB

Energy conservation for activity intolerance

Take your time & incorporate breaks into activities, rest 10 minutes per hour & 30-45 minutes after eating; do activities from seated position or with use of rolling cart Avoid temperature extremes (hot & cold) & extra movements for ADLs Items should be close at hand & at arm level Use good posture (standing or sitting tall without crossing legs) and body mechanics (2 handed flowing movements, pushing vs. pulling)

Urinary Incontinence #3

Transient Incontinence -Acute-onset that is reversible; not caused by permanent injury to nervous system -Can result from excess urine output secondary to other disorders (endocrine problems, CHF, sleep apnea, UTI, urogenital inflammation, overhydration) -Some drugs can cause this & disorder can also be found in people who have depression, psychological issues, or delirium -Patients w/ restricted mobility can develop, as can those w/ constipation or dehydration; once underlying cause is addressed, usually subsides Established Incontinence -Usually either urge or stress incontinence or a mixture of the 2 -Stress: occurs mostly in women w. altered pelvic floor & prolapsed urethra (also men w/ prostatectomies) --Detrusor muscle does not contract properly & pressure builds up in abdominal area, resulting in urine loss --Management: use of bladder training & pelvic floor exercises; drugs (estrogen, tricyclic antidepressants, or alpha adrenergics), or surgery -Urge: d/t powerful urge to void; if detrusor muscle is unstable & contracts/reflexes too often, one type of urge incontinence is called overactive bladder; bladder also contracts involuntarily & causes type of incontinence through some soft of sensory input, causing detrusor instability -Overflow: constant dribbling w/ frequent small volume emptying d/t obstruction or loss of contractility --Managed w/ behavioral techniques & pharmaceutical agents, primarily anticholinergic drugs Toileting & Assistive Devices -Many types of absorbent pads & underwear; easily opened clothing closers (Velcro) or aids such as reachers or zipper pulls; options of hygiene management (bidets, gender-specific urinals & bedpans, external collection-often occlusive-devices) -Urinary drainage bags & unique commode configurations (over-the-toilet, bedside, or riser) -Women: devices that support bladder neck or inhibit bladder prolapse (rings or donuts) -Men: penile clamps -Catheterization devices: adjuncts to perform associated functions such as catheter holding, clothing management, labia spreading

Analgesics

Tylenol-most common for fever and mild-moderate pain Moderate-severe pain treated with opioids: morphine, dilaudid, oxymorphone, oxycontin, fentanyl

Drugs used to treat diabetes mellitus

Type I (insulin dependent): Humulin R, Lantus Type II (oral meds): Glucotrol, Precose, Avandia, Glucophage

Cardiac rehabilitation card #2

Inpatient Cardiac Rehab -3 stages --1) Inpatient: begun during hospitalization --2) Early outpatient: supervised program up to 2 months after d/c --3) Lifetime maintenance -Guidelines for inpatient cardiac rehab: early eval & mobilization, ID of cardiac & self-care risk factors, education of pt & family, & an all-inclusive d/c session including transition plans -Inpatient rehab is 3-4 days, beginning shortly after MI or CV surgery; before starting, must be stable -Cardiac rehab member must determine baseline HR, BP, cardiac rhythm, heart & lung sounds, MS strength, ROM, & self-care potential -Based on severity of cardiac problem, supervised, progressive exercise is begun; low-moderate intensity strength training, ROM exercises, walking, & aerobics Stability & Suitability -Must meet certain criteria -In previous 8 hours, should not have had new/recurring CP or significant heart rhythm or EKG changes; should not have any fresh signs of uncompensated failure (CP while resting w/ bibasilar rales); CK & troponin should have no rise in levels -Once in exercise program, guidelines for progression to higher levels r/t heart activity parameters --HR sufficient, no novel rhythm or ST changes, new symptoms of cardiac problems (palpitations, SOB, CP) should not be present --SBP should elevated 10-40mmHg above resting levels during activity --Precautions against DVTs & PEs must be in place Admittance to Outpatient Program -Before admission, team must take medical hx, physical exam, resting EKG, & exercise test --Exercise test: treadmill protocol to determine risk stratification & suitable exercise program -If can walk @ 70% of their age predictive rate, considered candidate -Other forms of exercise testing: exercise nuclear testing, echocardiography, pharmacological stress test, arm crank ergometry, stationary cycling, 6 minute walk -Stratified for risk of cardiac events & undergoes psychosocial testing to ID depression, lack of self-esteem, & other factors that might impact participation

Neurotransmitters & Neuromodulators

Acetylcholine: transmits nerve impulses at various sites in brain, brain stem, & ANS to muscles -Mode of action: primarily excitatory Serotonin: released from brain stem, hypothalamus, or dorsal horn of spinal cord -Acts in inhibitory manner to suppress spinal cord pain & emotional responses Dopamine: released at base of brain & usually acts by inhibiting movements &responses Norepinephrine: present at many junctions & is primarily stimulatory Nitric acid: released from neurons & stimulatory

Drugs affecting CNS (central nervous system)

Antidepressants: SSRIs (Paxil, Prozac), Wellbutrin Anticonvulsants: 1st gen-Dilantin, Tegretol, Depakote; 2nd gen-Topamax Anticholinergics: Cogentin, cabidopa/levodopa (Sinemet)

Pharmacokinetics

Assessment of body's response to meds, variables are half-life & creatinine clearance

Drug classes in management of osteoporosis

Bisphosphononates -Fosamax inhibits bone resorption *drug class of choice for prevention* Selective estrogen receptor modulators (SERMs): Evista, Nolvadex Forteo treats osteoporosis by promoting bone formation & contains calcitonin-salmon Hormone replacement therapy (HRT)-no longer suggested d/t potential breast cancer & CV disease concerns

Therapeutic Positioning card #1

Basic Positions -Patient w/ limited mobility needs to change position regularly to avoid discomfort & a range of problems, including edema & loss of sensation; 4 basic positions of optimal therapeutic positioning; nurse can aid patient in changing to these positions -1st: lying on back (or supine) w/ a small pillow under head, neck, & shoulders & trochanter roll under hips -2nd: lateral or side-lying which uses several pillows to support body at head & neck, at upper arm, in front of lower leg & behind back; lateral is recommended for those who have had CVAs -3rd: prone or abdomen-lying position, patient's head is turned to one side for breathing & head, knees & hips, toes & feet are propped up w/ pillows -4th: 30 degree lateral position, positioned onto back w/ pelvis inclined at approximately 30 degrees to bed & limbs flexed; pillows used to support extremities where necessary; may be placed between knee & leg area, behind one arm, & behind head Patients in Wheelchairs -Those capable of using w/c should be seated w/ feet level to floor, footstool, or footrests preferably w/ shoes on for additional safety; weight should be symmetrically balanced over hips; important to use w/c that conforms well to body in terms of correct firm seat cushions & back supports -Pressure exerted on patient by chair should be spread out evenly; any cushions that cut off circulation or compromise skin integrity should not be used; adjustments or pillows or armrests for support may be needed; if needs a permanent w/c, should be custom ordered Positioning Aids -Pillows or folded towels commonly used to relieve & align & stabilize patient; also specially designed positioning aids; include trochanter rolls designed to prevent outward rotation of hip while prone, hand rolls, or hard cones that are placed under the hand keep it in place & prevent it from contracting, & abductor wedges or pillows that keep the prosthesis stable after THR surgery -A variety of splints or orthotic braces are available that either give support without allowing movement (static) or permit some motion (dynamic); include short & longer leg braces, walkers, specialized shoes, & orthoses made specifically for particular conditions -Casts are more supports made of plaster, plastic, or fiberglass; used for fractures as well as prevention of cardiopulmonary complications in postural conditions such as scoliosis or contractures d/t issues such as burns, RA, or limp muscles

Drugs used to enhance pulmonary function

Bronchodilators: albuterol, epinephrine, terbutaline Anticholinergics: ipratropium (Atrovent), tiotropium (Spiriva) Anti-inflammatory: Qvar, Azmacort, Intal, Singulair

Drugs used to control bowel elimination

Bulk forming: Metamucil, Fibercon Laxatives (irritate colon) -Emollients: Colace, may contain potassium or calcium -Stimulants: Senokot, Dulcolax -Hyperosmolar: Glycerin, lactulose -Saline-derived: oral magnesium citrate

Diagnostic tests for pulmonary problems

CXR: r/o cardiac disease, cancerous lesions, presence of FB Pulmonary function test: forced vital capacity (VC), forced expiratory volume in 1 second (FEV1), functional residual capacity (FRC), residual volume (RV), and total lung capacity (TLC) ABGs: measure O2 and CO2 pressures, bicarb levels, and pH Pulse ox: measure O2 6 minute walk test: walk casually for 6 minutes and watch for any O2 desaturation, SOB, or elevated HR

Brain Injuries card #2

Causes of Traumatic Brain Injury (TBI) -TBI: an insult to the brain caused by external influence that triggers deterioration of alteration of consciousness such that cognition or physical functioning is impaired either permanently or temporarily --Main cause in US is MVAs, especially motorcycle crashes; in elderly & young children, chief TBI reason is fall; participation in team or individual sports or certain recreational sports is another source for TBIs -Violence, ranging from firearm use (including combat related) to shaken baby syndrome, is another leading cause of TBI & in many causes death; collisions in sports such as football or soccer, boxing & bicycle falls (w/o helmet) are among activities resulting in TBI -Repeated concussion, mild blows to head causing disorientation or temporary unconsciousness, can eventually lead to cognitive dysfunction; ETOH or substance abuse can accentuate TBI effects Types of TBI -Can occur at time of impact (primary) or sometime after incident (secondary); primary injuries are either open head injuries in which brain matter is actually bared to outside elements through piercing by fracture or missile, or closed head injuries where head collides w/ outside surface but no brain matter is exposed directly to environment -4 main types of closed head injuries --One: concussions, minor transient synaptic disruptions possibly accompanied by brief LOC --Two: diffuse axonal injuries, more dispersed & potentially permanent synaptic damage caused by tearing & pulling --Three: contusions, bruising of brain tissue caused by internal collisions between it & skull --Hematomas: internal pools of blood caused by hemorrhage or measured leakage from blood vessels -Common late or secondary complications of TBI are seizures, abscesses, or hydrocephalus (buildup of CSF); seizures can occur anywhere from immediately after injury to weeks later w/ possibility of development of post-traumatic epilepsy greatest in latter

HIV card #2

Causes, manifestations, & rehab in children -Most contract disease from mother during perinatal period; current assumptions are 1/3 develop HIV in utero & 2/3 contract it during L&D -HIV tests of these 2 populations show + results at birth & seroconversion at about 2-4 weeks after birth, respectively -HIV transmission from + mothers can be greatly reduced through use of zidovudine (AZT) by mom & infant --HIV Symptoms in infants: FTT, lymphadenopathy, hepatosplenomegaly, oral thrush, diaper rash, chronic diarrhea, otitis media, nasal discharge --Later in childhood: neurological & other HIV associated problems develop -Much of rehab effort is directed toward cognitive development & therapies to offset motor deficiencies, antiviral meds are given to lower viral load Assessment of immunodeficiency -Nurse does history, systems review, physical & psychosocial evaluations --History: should include risk factors, med history, past/present opportunistic infections, weight prior to illness --Neurological: cognitive defects & peripheral neuropathy --GI: diarrhea, malabsorption, nutritional problems --Skin: rashes, lesions --MS: weakness, incapacity to perform ADLs --Psychological: depression, coping issues --Constitutional: fever, wasting, or pain --Look for evidence of opportunistic infections & ID functional limitations --Psychosocial evaluation: adherence to meds, addressing substance abuse, coping skills, sexuality, & social support Diagnostic tests -Confirmed by lab diagnostic tests --ELISA: enzyme-linked immunosorbent assay (HIV dx) --Western blot: electrophoretic technique which IDs HIV-related proteins, particularly p24 -Viral load determined by HIV RNA polymerase chain reaction (PCR) or branched chain DNA (bDNA) -Disease progression: looks at CD4+ T-cell count --More advanced tests can classify genotypic & phenotypic to see if mutations may render resistant to current antiviral drugs -Frequent blood glucose & lipid levels are taken d/t high incidence of metabolic abnormalities Diagnoses, interventions, & goals applicable -Diagnoses: risk for infection, imbalanced nutrition (less than body requirements), diarrhea, chronic pain, fatigue, & disturbed thought process -Educate about disease process & med use, nutrition & oral health supervision, management of diarrhea, pain, fatigue, & dementia or other cognitive impairments -Psychological diagnoses: risk for ineffective therapeutic regimen management, ineffective coping (also disabled family coping), hopelessness, & ineffective sexuality pattern --Can be addressed through health ed to promote med adherence, coping enhancement strategies, emotional support, & sexuality discussions

Impaired gas exchange

Common in those with chronic lung disease like COPD, asthma, and bronchopulmonary dysplasia (BPD) in infants Primary intervention is O2 therapy; in order to be reimbursed for home O2 therapy, pt must have pulse ox of 89% or lower while at rest or walking

Subjective appraisal of respiratory complaints

Dyspnea: appraised using subjective Borg CR10 scale (r/t rest & exercise) Cough: useful in clearing airways and preventing aspiration; but if unrelenting, painful, or produce mucus, may be sign of problems; sputum characteristics suggest source, infections often produce thick, green, odorous sputum; blood suggests airway or vasculature problems Intolerance of physical activity: r/t SOB and/or rapid fatigue with activity

Impaired physical mobility

Devices Traction: allows mobility during healing -Skeletal plus trapeze, Halo vests, Ilizarov device (separated bone ends, allowing them to align & heal) Ambulation aids -Double-support walkers, canes, and crutches Principles of care -Joint mobility exercises, use biggest & stronger joints -Positions changed often, frequent rest periods, strength training, pin care, training of caregivers in assistive device use

Coping with Health Issues card #4

Diagnosis Relevant to Ineffective Coping -Primarily relevant to patient, family, or community; these pertaining to pt include anxiety, fear, risky behaviors, grieving, lack of hope, low self-esteem, & a number of ineffective coping mechanisms; family can be diagnosed w/ other coping & stress-related issues such as grieving, caregiver role strain, fear, interrupted family procedures or coping, or powerlessness; inclination toward or ineffective community coping is another type of diagnosis Interventions & Outcomes for Prevalent Coping Diagnoses -2 coping styles: ineffective & defensive coping, show that nursing intervention is needed -Ineffective coping: nurse should provide support that enhances person's ability to cope, make decisions, & control anger & builds self-esteem & enlarges their support system -Defensive coping: interventions r/t self-awareness & fostering of relationships are important; in each desired nursing outcome is person's acceptance of their health status -Another common dx is hopelessness, can be addressed through support groups, therapies, & relationship building that inspires hope; main goal is improvement of mood & enhancement of will to live -Dx of impaired social interaction indicates need for a number of interventions to improve pt's environment, resiliency, self-esteem, & awareness; it is to be hoped that these interventions will lead to improved social atmosphere & patient involvement -Classification of chronic sorrow generally addressed through facilitation techniques (including support groups) that work through & resolve grief; nursing interventions for caregiver role strain include support & respite care to enhance emotional health & performance

Gerontological rehabilitation card #3

Disturbed sleep pattern -About 50% of adults over age 65 have this resulting in insomnia (inability to fall asleep or remain asleep long enough to feel rested) -Insomnia: less than 6 hours of daily sleep, the need for more than 40 minutes to fall asleep, or tenseness upon awaking -Main causes r/t aging: urgency to urinate, aging-associated changes such as lower blood flow, waning of sleep patterns stages 3 & 4 (non REM deep sleep) probablt d/t morning alterations in core body temp, disease-related pain, and specific sleep-related pathological conditions -Behavioral modifications (preferred over sleep meds): nighttime denial of fluids, elimination of caffeine-containing foods & drinks, relaxation therapies, & changing behavioral patterns (getting up if not asleep within 30 minutes, controlling number of hours until return to normal pattern, & restricting other activities in bed) Chronic pain & depression -Pain often under reported by elderly d/t fears about pain med addiction, lack of ability to communicate pain, or other factors; should be viewed as real if conveyed -Visual analogue scales are best -Consequences of depression measured using Geriatric Depression Scale (30 questions r/t quality of life & possible depression, score with 1 or 0) -Lower risk pain management options are APAP & NSAIDs which may be taken along with antidepressants (SSRIs) or tranquilizers; if d/t OA, glucosamine & chondroitin are useful -Alternative modalities: biofeedback, hypnosis, guided imagery, massage Acute Confusion -Lack of clarity occurring abruptly & transiently -Characterized by changes in cognition, degree of consciousness, physical & mental activity, sleep pattern, & possible short-term memory -Can be d/t some precipitating event, but often occurs in people with other chronic or comorbid conditions -Many classes of drugs can cause episodes of acute confusion or delirium; tricyclic antidepressants, antipsychotics, anticholinergic agents, antiarrhythmics, corticosteriods, NSAIDs, antibiotics, & narcotic analgesics -Usual course of action: review meds being taken to ID possible cause; then drug is either temporarily or permanently withdrawn

Coping with Health Issues card #2

Factors that Affect Coping -Many are r/t sense of self & abilities, these include sense of coherence, self-efficacy, internal locus of control, optimism, hope, hardiness, & resourcefulness; individual has sense of coherence if they responds to stressors w/ desire to cope & perception that they understand & have available resources to address challenge -Concept of self-efficacy, belief in oneself that a course of action can be developed & executed, is similar; people w/ high internal locus of control believe that their own actions can influence outcomes; optimism & hope are interrelated concepts -Optimism: expectation of favorable outcome; hope=faith in improvement; optimistic people generally employ active problem solving in coping process, whereas hope is a more emotional concept; hardiness refers to inherent ability to withstand adversity & resilience is capacity for speedy recovery; resourcefulness or ingenuity is a learned process that can aid ability to cope -Degree of uncertainty or lack of predictability of desired or certain outcome, influences other coping mechanisms; uncertainty can lead to frustration, hopelessness, aggressive behavior, & feeling of hopelessness in pt & family' members -Social support systems have been found to greatly enhance coping mechanisms in both pt & family, particularly within 1st few months after injury; there have been a number of studies that suggest ability to cope can be influenced by age, gender, educational level, ethnic background, & existence of other comorbid conditions

Assistive devices for self-care activities

Help conserve energy: long-handled shoehorns, long-handled curved brushes for bathing, reachers that help alleviate need to bend (good for THR patients), raised commode seat, motor drive prostheses, elastic shoelaces, Velcro closures

Renal system & disease card #3

Hemodialysis (HD) -A process by which blood is filtered through artificial kidney & then returned in ultrafiltrated, normalized form -Normally done in hospital setting or dialysis tx center, but sometimes done at home -Typical tx schedule is 3 times/wk on alternate days for 3-4 hrs/session -Hemodialysis system starts w/ vascular access through internal AV fistula or looped graft in forearm (or thigh, intrajugular, or subclavian veins) -Blood passes through pump, infused w/ heparin, is filtered in dialyzer -Filtered blood then returned through 2nd needle Other aspects of ESRD -Must watch diet & fluid intake carefully per renal dietitian -Guidelines for daily intake: 1-1.5 grams protein/kg, 2-3 gm NA, 60-90 mEq of KCL, 600-800 mg phosphorus, & 1-1.2 liters of fluid; urine output is monitored -Dialysis regimen affect blood glucose levels in patients with DM because glucose is incorporated into dialysate fluid & BP is often depressed after dialysis -May require many meds: antihypertensives, iron supplements, insulin, phosphate binders (for stool elimination), antidepressants, or human growth hormone (children); epoetin alpha (& iron) usually injected IV or SQ during dialysis to bolster erythropoietin & RBC levels (minimizes anemia) -Mild to moderate exercise is suggested if possible -Prone to psychosocial & emotional problems Peritoneal dialysis (PD) -Home based dialysis alternative that uses peritoneal membrane of abdomen as filter & a surgically implanted catheter -2 versions: continuous ambulatory peritoneal dialysis (CAPD) & continuous cycling peritoneal dialysis (CCPD) -Exchange is done daily, either manually 3-5 times/day using Y-set (CAPD) or using cycling dialysis machine during sleep (CCPD)\ -Both require self-care & sterile techniques that can be learned through rehab team & visits by nephrology RN & social worker -Dietary restrictions less than HD, but may need more insulin & should still monitor BS levels; may need to consume more protein d/t albumin less in effluent -Peritonitis: inflammation of abdominal lining, is a possible critical complication attendant to infection -PD patients are generally much more active, independent, & relatively free of psychological & emotional problems

Objective assessment during physical examination

Inspection: Good lighting, have patient lie down Palpation: Listen for a pattern of sound transmission Percussion: Determines degree of resonance Auscultation: Anything besides clear LS

Autonomic nervous system (ANS)

Involuntary arm of peripheral nervous system -Divided into: --SNS: Controls stress (survival) responses (pupil dilation, vasoconstriction, sweating, increased heart rate, bronchial dilation, augmented basal metabolism) --PNS: Controls involuntary (maintenance)responses (pupil constriction, decreased heart rate, bronchial construction)

Sexuality in Disabled Patients card #2

Interventions for Psychosocial Issues & Sexuality -Most prominent psychological issues r/t sexuality in disabled patients are disturbed body image & chronic low self-esteem; nurses roles are to educate patient abut expected changes, retrain them in aspects that might affect body image or self-esteem (control of incontinence), & provide supportive environment; they often feel social isolation as well, which can hamper their ability to foster interpersonal & romantic or sexual relationships -Interventions: clothing or cosmetics that mask parts affecting body image can alleviate feeling of social isolation; they need to be educated that in most cases lovemaking is still possible; sexual rehab involves development of positive communication patterns w/ partner taking into account that women are more attuned to underlying emotions than men who are more lateral -Healthcare personnel should provide privacy for pt & pt's partner to express affection such as touching, hugging, & kissing Safer Sex Guidelines for disabled patients (or anyone) -1. Should be taught that abstinence is only absolutely safe means of birth control & prevention of STDs -2. Pt should be advised that STDs are less likely w/ restriction of number of sexual partners, mutually exclusive sexual partnering, & prior knowledge about partner's sexual hx -3. High risk activities should be avoided until STD status is known; these include unprotected vaginal or anal intercourse & any other activities that can expose individual to blood, semen, feces, or secretions -4. Condoms can greatly reduce spread of STDs & should be used w/ oral, anal, or vaginal sexual practices & combined w/ spermicides, such as octoxynol or nonoxynol-9, for the latter 2 -5. Lubrication, hygienic practices, & voiding after sex further decrease likelihood of infection -6. People at risk for STDs, especially HIV, should be tested & examined periodically -7. If sexual stimulators (vibrators) are used, should be cleaned completely before use & w/ lubricants

Other surgical interventions for musculoskeletal problems

Laminectomy -Portion of lamina is removed Discectomy -Some or all of a ruptured intervertebral disk is removed Foraminotomy -Widens foramen portion to make room for spinal nerve Spinal fusion -Several vertebrae are stabilized by insertion of bone grafts & sometimes other devices Decompression -Bones or tissues are taken out to eliminate pressure on spinal nerves

Drugs to improve mobility

Muscle relaxants: baclofen, Zanaflex Disease modifying: methotrexate (drug of choice for RA or Crohn's), Plaquenil, Remicade, Kineret, Enbrel

Anti-inflammatory drugs

NSAIDs: Aleve, Indocin, Relafen (subclass is COX II inhibitors-Celebrex) Corticosteriods: Decadron, Cortef, Deltasone

Gas transport & exchange

O2 binding to hemoglobin & transport to tissues is dependent on arterial O2 pressure, cardiac output, and perfusion rates CO2 transport is a reflection of metabolic activity and diet

Spinal Cord Injuries (SCIs) card #4

Other Problems & Goals for Treatment -Often develop neurogenic pain within first months after injury; nurse needs to stress proper posture & alignment to decrease likelihood of muscle spasms & pain, & also develops long-term pain management plan (usually w/ meds); within same time frame, may experience heterotrophic ossification or excessive growth of bone in soft tissue in joint, resulting in decreased ROM, pain, & spasticity; ROM exercises & pharmacologic interventions are indicated in this case -Osteoporosis (excessive reabsorption of bone relative to formation), occurs particularly in initial year after injury d/t decreased mobility predisposing patient to fractures; weight-bearing exercises are indicated; social & emotional adjustments are difficult for many individuals & depression is prevalent in group; nurse can help by being observant, planning self-care programs, & identifying community resources Motor & Sensory Effects of Cervical Level Injuries -UMN injuries encompass damage to C1-C8 as well as T1-T10; for the most part, patients can't feel sensations or perform voluntary movements below level of injury; therefore if damage occurs at C1-C3, patients will be vent dependent & very limited capabilities & mobility; they may have head movement, but there will be sensory loss in certain areas & diaphragm + intercostal muscles will be paralyzed -If next C4 segment is injured, patients may have some diaphragm function & shoulder movement, & may be able to breathe on own without a vent or themselves at times; as highest level of damage to spinal cord moves lower (C5 + C6), certain muscle groups in UEs become functional; sensations in UE are present in individuals w/ these injuries, & the possibility of independent living increases -Those w/ C7 injuries can support normal breathing patterns, have most UE sensations, & can usually function independently; those w/C8 have full sensation in hands, can flex fingers, have normal arm & shoulder positions, & can functions independently Motor & Sensory Effects of Thoracic, Lumbar, & Sacral Level Injuries -Damage to upper thoracic spinal segments is still considered an UMN injury; if T1-T5 sections are involved, pt has full control over their UEs, can feel down to middle chest & back area & has some functionality of intercostal & thoracic muscles; this means pt also has normal pulmonary functions, fairly good balance, & can function using just a manual w/c -If damage is lower at T6-T10 levels, parameters improve further; when lower thoracic, lumbar, or sacral levels are highest levels affected, SCI is a LMN injury; from T11-L5, motor functions in hips, knee, & foot progressively return & sensations are present in abdomen, hips, & certain areas of leg; however sensation is not present in genital or buttock regions; S1-S5 injury patients can eventually gain complete control of LEs, manage elimination & sexual functions, & feel sensation in all areas, including groin; there pt's w/ LMN injuries can eventually perform self-care & ambulate w/ leg braces or independently

Medical home

-2005 article from journal Pediatrics=outlined care coordination for special needs children in medical home -Physician created care plan that aids in keeping child & family informed on clinical issues, provides reasons for referral, evaluation of recommendations from consultants -This care plan is placed in comprehensive, accessible, confidential central database at PCP's practice -Ideally, family & community resources are included in plan & made available

Nerve Fibers in Lower Urinary Tract

-3 types of PNS nerve fibers that supply lower urinary tract & other areas: parasympathetic, sympathetic, & somatic fibers -Parasympathetic nerve fibers control unconscious & involuntary functions; main fibers innervating lower urinary tract comprise pelvic nerve, initiates bladder contraction; other fibers facilitate voiding by augmenting urine transport in ureters, contracting detrusor muscle, & opening internal sphincter -Sympathetic: control other autonomic functions such as stress responses & changes in muscle tone; aid bladder storage by slowing down urine transport in ureters, easing detrusor muscle, & constricting internal sphincter (all in opposition to parasympathetic functions) -Somatic: voluntary control & either efferent (stimulating motor responses in external sphincter & pelvic floor via pudenda nerve) or afferent (transmitting sensory responses from bladder to spinal cord)

Uninhibited, Reflex, & Autonomous Neurogenic Bladder Dysfunction

-5 types; 3 result from central nervous system damage; uninhibited, reflex, & autonomous -Uninhibited: characterized by numerous uninhibited contractions & complete voiding without residual volume; caused by brain or subcortical area lesions -Reflex: little or no awareness of voiding pattern, occurs as reflex instead of voluntarily; etiology is upper spinal cord injury involving both motor & sensory tracts of region down to about T11 -Autonomous neurogenic bladder: awareness of fullness, dribbling, & involuntary emptying d/t bladder overflow as a result of lower neural damage to sacral reflex arc

Senses of Touch & Sensation

-6 kinds of sensory receptors; mechanoreceptors are situated within skin & are involved w/ sensations of touch, vibration, flutter, & pressure; there are also propriceptors in muscles or other soft tissues associated w/ sense of position, thermoreceptors in skin that sense heat & cold, nociceptors that react to pain or injury, chemoreceptors responsive to chemical stimuli, & photic receptors that respond to light -Latter 2 are not particularly associated w/ touch; each receptor converts energy from stimulus into an electrical signal, which is carried to brain or spinal cord; sensation is disturbed in many neurological diseases

Dyslipidemia

-A condition is which one or more lipid parameter is outside normal ranges -Healthy ranges: total cholesterol level <200mg/dl, HDL >40mg/dl (men) & 50 mg/dl (women), LDL <100mg/dl, & triglycerides <150mg/dl -Other risk parameters: family hx, HTN, tobacco use, age of >45 (men) or >55 (women) -Tx: individualized, LDL & triglyceride level reduction; statin drug class, lifestyle modifications-reduction of saturated fat & cholesterol intake, more fiber

HIV card #1

-A retrovirus: genome is made up of RNA vs DNA, uses reverse transcriptase (enzyme) to replicate within CD4+ T lymphocytes of host -Normal immune system has 3 cell types in immune response (T cell, B cell, & macrophage) -HIV infection is chronic with most severe cases developing into AIDS Progression -1st phase: very infectious, primary & symptomatic infection; seroconversion (evidence of viral particles or p24 antigen) within 6 months; anti-HIV antibodies may be undetectable at this time -Asymptomatic stage: viral replication & antibody production, can last up to about 8 years -Symptomatic stage: persistent generalized lymphadenopathy (PGL), weight loss, fatigue, fever -Last stage (AIDS): opportunistic infections or strange malignancies begin to emerge & many systems show deterioration; CD4+ cell counts go down (~1000 cells/mm3 at onset), dropping to 200 cells/mm3 in full blown AIDS -Timeframe for each of last 2 stages was a couple years, but antiretroviral therapies can greatly delay progression Opportunistic infections & physical changes -With disease progression, immune system become more compromised & CD4+ counts decrease -TB & oral thrush are 2 early opportunistic infections, usually showing up when CD4+ counts are < 350, followed by pneumocystic carini pneumonia (PCP) & herpes simplex -When CD4+ counts are very depressed, other infections & novel malignancies: non-Hodgkin's lymphoma, cytomegalovirus, toxoplasmosis, systemic fungal infections, Kaposi's sarcoma, & Mycobacterium avium complex (MAC) -Central & peripheral system disorders occur as AIDS progresses; some may be responsive to antiviral meds that cross blood-brain barrier -Neuromuscular difficulties lead to muscle wasting -Tend to develop intestinal infections & diarrhea; progressive weight loss (w/ anorexia) d/t compromised nutritional status as a result of lowered intake, malabsorption, or hormonal or metabolic aberrations; most c/o fatigue

Venous Thromboembolism (VTE)

-A vein blocked by a blood clot or thrombus that has detached from original site -Initial criteria for risk are reduced mobility + at least 1 VTE risk factor -Risk factors: over 40, previous hx of VTE, related diseases (thrombophilia, collagen-vascular disorder, varicose veins, inflammatory disorders); other risk factors: obesity, ICU admission, CVC, nonhemorrhagic CVA, HF, cancer, chronic lung disease or resp. failure, pneumonia or other serious infection -If patient has hypersensitivity to heparin or thrombocytopenia induced by it, active bleeding, uncontrolled HTN, a clotting disorder, recent cranial or eye surgery, or recent spinal tap or epidural anesthesia; they are given SEDs -Otherwise, at risk patients are given Lovenox 40mg SQ QD or Heparin 5,000 units SQ q 8 hours Signs, Diagnosis, & Interventions (DVT) -Signs: acute pain, edema, deep muscle tenderness r/t inflammation, fever, lethargy, elevated WBCs, elevated ESR, swollen feet/ankles -If larger veins are involved, systemic reactions may occur, resulting in high fever -DVT must be detected & managed early in order to prevent PE -Dx: D-dimer test, duplex US, contrast venography (gadolinium w/ MRI or ascending) -NU diagnoses: ineffective peripheral tissue perfusion, anxiety, ineffective therapeutic regimen management -Interventions: stop clotting through use of anticoagulants such as heparin or warfarin, dissolve existing clots, thwart clot migration, support patient, remove blood clot (some cases); pain meds, elevation of extremity, TEDs, maintain ROM & mobility

Intellectual disability

-All definitions refer to intellectual limitations that began during childhood, each is used to qualify individual for various services -American Psychiatric Association (APA) DSM IV definition "a) significantly sub average intellectual functioning: an IQ score of approximately 70 or below on an individually administered IQ test, b)concurrent deficits or impairments in present adaptive functioning in at least 2 of the following areas: communication, self-care, home living, social/interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health & safety; c) the onset is before age 18 years" -Degree of intellectual disability is further classified by APA as mild (IQ 55-70), moderate (IQ 40-55), severe (IQ 25-40), profound (IQ <25), or unspecified (can't be evaluated) -American Psychological Association slightly different then APA: defines cognitive deficit as "significant coexisting limitations in intellectual & adaptive functioning beginning before age 22" -American Association on Intellectual & Developmental Disabilities (AAIDD) sees disorder defined by amount of support required rather then IQ; intermittent & limited support=mild & moderate disability and extensive & life-sustaining support=severe & profound disability -Dx: Broad medical, gestational, developmental and family history (includes mother's prenatal exposures and hx of developmental problems in family); Physical exam that looks for any unusual or dimorphic body features (suggestive of disrupted fetal development); developmental testing is done; Bayley Scales of Infant Development or older child IQ tests are given based on physical age; labs tests-chromosomal, metabolic (phenylketonuria); imaging or electrophysiology studies

Neuromuscular disorders

-All share common traits such as the systems compromised (respiratory, speech, swallowing, ambulation) & typical palliative measures (maintenance of function, self-care education) -Care requires much planning because is debilitating & usually progressive -Team members: respiratory therapist, speech pathologist, dietitian, urologist, enterostomal RN, psyhosocial professsionals, PT/OT staff, sexual therapist, MD, and primary RN Drug classes -Antidepressants & stool softeners (used for SCI, ALS, GBS, HD, MG, MS, & PD) -Corticosteriods, immunomodulators, methotrexate, T-cell receptor peptides, & monoclonal antibiodies (used to suppress immune/inflammatory responses); methylprednisolone reduces swelling & improves blood flow (SCI) -Cholinergics, anticholinergics, muscle relaxants, antispasmodics, dopaminergic drugs, MAO inhibitors, antihisamines, & COMT and GABA antagonists addresses neurotransmission and/or muscle properties & are used to manage symptoms such as urinary retention or frequency, spasticity, bradykinesia, tremor, & rigidity (MS, PD, SCI) -Antioxidants used to slow progression (PD)

Sense of Taste

-Alterations in taste are not life-threatening, but can affect quality of life; can be affected by aging, cigarette use, desquamation of tongue, radiation of the area, infections, & strokes -Taste buds: nerve endings on tongue surface & mouth that send signals to vagus, glossopharyngeal, & facial nerves to thalamus & then to ipsilateral gustatory cortex in cerebrum -Different portions of tongue are sensitive to one of 4 kinds of tastes, sweet, salty, sour, or bitter; these sensations can be evaluated in patients w/ poor appetites & invariable response to foods; this is done by saturating cotton swabs w/ solutions of sugar, salt, lemon juice, or coffee & then placing one swab at a time on the tongue to see if person can distinguish the category

Physical Exam of Musculoskeletal & Neurological Functions

-Assessment may be subjective or historical; medical hx or recording of pt's ability to perform ADLs may be taken -Includes parameters that provide objective assessment of pt's situation; should encompass observations related to MS or neuro function, such as posture, alignment, skin color & rigidity, gait, & resp. status -Nurse or other clinician should evaluate ROM & other joint health; need to evaluate muscle strength, using manual muscle test to determine ability to flex, relax, & grip; muscle tone, using palpation; motor stretch or deep tendon reflexes, by striking of specific tendons; cranial function, by assessing vision & eye movements; sensory responses in trunk & extremities, by dermatome or other mapping; kinesthesia or spatial perception, using moving finger and/or tuning fork; balance & coordination while seated or while performing ADLs; gait pattern; & ability of pt to perform ADLs, by observation

Myasthenia gravis

-Autoimmune disease: IgG autobodies are generated against acetylcholine receptors because self-recognition of these receptors are destroyed; then, acetylcholine can't transmit nerve signals across neuromuscular junctions & several types of muscle weakness occur -Usually affects ocular muscles, bulbar muscles that control throat functions, or may be more generalized -Develops subtly, can be highly progressive -Myasthenic crises occur with insufficient meds-anticholinesterase being drug of choice; over administration of drugs may cause cholinergic crisis (neuro functions beyond baseline are abnl) -Tests: Tensilon administration (rapidly increases muscle strength), evaluation of nerve conduction using electrophysiology, serum titers for antiacetylcholine receptor antibody, and CT scans to look for enlarged thymus -Interventions: most address immune & inflammatory nature of disease --Immunosuppressant drugs: azathioprine (purine antimetabolite), cyclosporine, cyclophosphamide, & mycophenolate --Plasmapheresis: blood is taken out, treated to remove harmful antibodies & immune complexes, & returned to the patient --May receive IV immunoglobulins or have thymus removed --Immunomodulators given during difficult periods or anticholinesterase agents to enhance neurotransmission

Lower Extremity Ulcers

-Besides PUs, neuropathic, arterial, & venous ulcers may occur in LEs; lost or abnormal sensory or motor responses are responsible for neuropathic ulcers --Most prevalent example: ulceration of foot in patients w/ diabetic peripheral neuropathy who have lost sensation & muscle tone at site -Arterial ulcers occur in lower extremities because there is decreased blood perfusion to area, resulting in PVD & propensity toward poor wound healing; when injury occurs to deep or superficial vein, HTN or high venous pressure occurs, predisposing them to venous ulcers (often result from thrombosis or formation of blood clots)

Spina bifida

-Blanket term for conditions present @ birth in which neural tubes in spinal column or meninges protrude though a cleft in column, resulting in loss of neuromuscular function below level of injury -Insufficient folic acid intake by mother during pregnancy appears to contribute to condition -Diagnostic components: LE paralysis & impaired physical mobility, elimination problems, & sexual dysfunction --Can be addressed though w/c use & exercise therapy, urinary elimination management & bowel training, self esteem enhancement -May have delayed growth & development -Increased risk for obesity, injuries, latex allergies, poor skin integrity & hydrocephalus (increased CSF around brain resulting in head enlargement & ICP) which is treated if present through use of shunts

Coronary artery perfusion

-Blood is supplied to heart through 2 coronary arteries arising from R & L sides of aorta -Amount of perfusion is r/t HR, cardiac cycle, diastolic intraventricular pressure -Diastole: rhythmic expansion & filling with blood of heart chambers -Systole: contraction of heart & pumping out of blood -If perfusion is altered, will have acute coronary syndrome (ACS) d/t inadequate blood supply signaled by CP -ACS could be stable or unstable angina or infarctions with or without Q-wave involvement -Biggest factor: increased HR with subsequent shortened filling time & depressed perfusion -Elevated circulating blood volumes (seen in CHF), can reduce blood flow to more distant subendocardial areas of heart d/t high diastolic interventricular pressure also resulting in ACS -Abnormalities w/ myocardial ischemia include CP, dyspnea, cough, stenotic lesions, infarctions, & elevated HR

Dyspraxias & Apraxias

-Both refer to inability to perform complex movements, especially as a result of brain damage (often d/t CVA); 5 main types of apraxia: ideomotor, conduction, disassociation, ideational, & conceptual -Ideomotor: inability to process sequential & spatial relationships of movement; is a posterior form, resulting from damage to left parietal cortex, in which person has trouble responding to commands & discriminating performance level; there is also an anterior form occurring further forward in same area that is less secure -Conceptual: damage to bilateral frontal & parietal areas & is characterized by inability to recall how to use certain tools or mechanical objects -Brain defect area of remaining 3 types of apraxia is uncertain -Conduction: can comprehend movements & gestures but have difficulty performing them -Disassociation: can perform well w/ objects but have poor verbal responses -Ideational: can't carry out an idea or sequence of actions properly

Diagnoses & Interventions for Bowel Elimination Problems

-Bowel incontinence can be d/t 5 types of neurogenic impairments; also d/t loss of muscle tone in GI tract, pressure in GI tract d/t gas, habitual laxative use, & poor bowel habits -Nurse's role: provide bowel incontinence care, management, & training in order to eventually achieve control, proper elimination, & skin integrity; if has true constipation, responsible for management of problem as well as fluids & nutrition -Some merely have perceived constipation, nurse's role (big part) is education; others can be at risk for developing constipation & clinician should incorporate a variety of interventions & meds -For diarrhea: interventions include management of problem as well as meds, general bowel habits, fluids & electrolytes, perianal care, & skin inspections

Neurological Classifications

-Brain & spinal cord comprise CNS; any nerve cells outside of these areas are part of the PNS; spinal nerves are designated according to area from which they exit spinal column; plexuses are networks of nerves that extend from front of spine & go the different areas of body; there are 4 plexuses, sacral, lumbar, brachial, & cervical -Messages carried from brain & spinal cord are said to be efferent of motor; while those transmitted from PNS back are afferent or sensory; involuntary actions are controlled by autonomous nervous system comprised of SNS & PNS -Sympathetic nervous system: involved w/ stress responses -Parasympathetic nervous system maintains normal equilibrium needed for functions involving glands & cardiac & other muscles

Brain

-Brainstem: apex of spinal cord & consists of 3 parts: medulla oblongata, containing reflex centers controlling cardiac & other functions: the pons, whitish band of nerve fibers; & midbrain, primarily concerned w/ sensory functions such as eye movement & balance -Cerebellum: located in lower & back portions of brain; controls several types of motor tasks, including coordination of motor movements (in conjunction w/cerebrum) & contraction of muscles in extremities; between midbrain & cerebrum is diencephalon, which contains several important glands -Cerebrum: occupies upper part of brain & directs complex efferent pathways; has 5 lobes defined by functional control & location; both cerebellum & cerebrum are divided into left & right hemispheres, & hemispheres in cerebral motor cortex control functions on opposite side of body -There are 3 white matter tracts in cerebrum, the association, ascending spinothalamic, & descending corticospinal tracts; basal ganglia are areas of gray matter that aid in regulation of voluntary functions

Cerebrovascular Accidents (CVAs)

-CVA (stroke) disruption of blood to area in brain; can be caused by extracranial factors (HTN or other circulatory problems) or by intracranial factors (tumors or hemorrhaging); main cause of disability in older people as well as 3rd leading cause of death in US; types of stroke that can occur are primarily thrombosis, embolic CVA, or hemorrhagic stroke -Thrombosis: formation of blood clots that block blood vessel; often accelerated by atherosclerosis in which cholesterol-containing plaques form on inner surface of an artery & can burst creating an opportunity for clot development -Embolic: occurs in people w/ CV problems (especially A-fib); here severe neurological problems can quickly occur after a blood clot originating in L atrium travels into brain blood vessel causing an infarction -In either case, brain swelling quickly occurs & neurological impairment is observed; blood vessels in brain can leak or rupture causing potentially deadly hemorrhagic stroke Signs & Management -Typically present w/ vague sensory & motor problems that are often associated w/ other issues such as numbness, speech problems, fuzzy vision, or loss of muscle control; symptoms may go away within a day & be ignored, even though permanent damage may be present; in vast majority of patients, L hemisphere is dominant language-mediating site; in this case, if stroke occurs in L hemisphere, speech & cognition will be affected -Collateral paralysis can result from damage to either hemisphere as well as other cognitive defects; in terms of management, initially location of CVA is pinpointed w/ CT or MRI scans & type of CVA is determined; non-hemorrhagic strokes if identified quickly can be treated w/ tissue plasminogen activator (TPA) & agents that reduce clotting such as aspirin or warfarin; if stroke occurred more than 3 hours prior to intervention, heparin or warfarin is given; steroids & diuretics may be administered to decrease intracranial pressure & a carotid endarterectomy may be performed Rehabilitation Goals -Should be directed toward improving functional abilities based on identified impairments; these patients can have a range of physical, cognitive, & behavioral issues; most common areas affected are attention span, memory, decision-making, perception, ability to choose, communication, mood, & emotional lability -Often dependent on others & may undergo a period of depression; can lose flexibility or have problems w/ mobility- thus, correct positioning & passive stretching are important rehabilitative interventions -Rehab program should address cognitive, physical, & language defects; there are a number of nursing approaches based on theory that brain can be retrained & some functionality restored through reprogramming; these include Motor Relearning Program & Bobath System

Altered Muscle Reflexes

-Called either dyspraxias or apraxias; result in inability to perform complex movements; term reflex itself refers to any involuntary or automatic response to provocation; if reduction in reflex quality or amount of reaction, hyporeflexia is occurring -Hyporeflexia is often observed w/ LMN syndromes; conversely, response that is magnified in terms of quality & amount is said to be hyperreflexia; usually happens because brain's ability to inhibit lower neuronal responses has been compromised as with SCIs

Dysarthria Therapy

-Can be approached medically & may include treatment of fundamental neurological disorder, laryngeal surgery (particularly for phonation), use of various pharmacological agents or injections (such as Teflon or Botox), respiratory support, or use of artificial devices -Speech pathologist is usually instrumental in diagnosis of articulation problems & design of exercises to improve various speech errors; these include exercises to strengthen palatal, laryngeal valve, or respiratory muscles to improve resonance, phonation, & respiration respectively -Behavioral management is another approach, which can range from compensation techniques such as breathing exercises & biofeedback to general procedures to improve speaking, listening, & interacting; modalities that circumvent or support actual speech and/or writing are known as augmentative & alternate communication (ACC) devices & include things such as printed signs, pictorial illustrations, symbols, sign language, speech synthesizers, & picture books & charts

Transferring Dependent Patient From Bed

-Can be transferred to other locations (w/c, toilet, bathtub) in many different ways; 1st is use of mechanical device like Hoyer lift , which picks up patient in seated position & then delivers & lowers patient into other site -2 caregivers can lift transfer patient from bed to chair by synchronizing transfer while one supports patient under arms, grasping opposite wrists, & other holds up feet & legs -A pivot transfer involves sitting patient on side of bed & then assisting transfer by having patient hold on & supporting patient's lower back

Relaxation Exercises

-Can help patients relax & distance themselves from pain, relaxation response can be generated through techniques such as self-hypnosis, prayer recitation, deep-breathing, muscle relaxation, or specific relaxation exercises --One exercise is use of slow, rhythmic breathing, usually initiated through abdomen & inspiring & exhaling same length of time (3 counts) -Touch techniques like massage w/ a warm lubricant and/or aromatherapy can promote relaxation; visualization & guided imagery techniques, providing comfortable environment incorporating familiar & pleasurable elements such as music or religious programming, & meditation practices can enhance relaxation

Sexuality Throughout Life

-Capacity for sexuality is present throughout life; however, there are changes in children that increase sexuality or interest in sexual activity as well as ability to reproduce -For girls, puberty or physiological maturity starts around 8-11, prompted by production of estrogen & other hormones -For boys, puberty begins around 9-15 & is marked by testicle, prostate gland, & other organ maturation & increased production of hormone testosterone -Aging: In postmenopausal women, hormone levels decrease, interest in or response to sex diminishes, & vaginal atrophy or other losses can occur; as men age, testosterone & sperm counts decrease; various sexual organs may atrophy & ejaculation force may be diminished

Medicine & food/nutritional status interactions

-Certain meds & herbal preparations affect nutritional status; some may cause accelerated depletion of essential nutrients: Lasix (increases excretion of NA, KCL, and calcium), cholestyramine (excretion of folic acid, vit. B12, fat soluble vitamins, iron, & calcium) -Others impede absorption of essential nutrients in GI tract, phenobarbital affects calcium absorption & habitual use of antacids or KCL depletes a number of vitamins & minerals -Some foods hinder/enhance absorption of certain meds; amino acids or carbs (decrease/increase-respectively assimilation of levadopa, phenytoin, & theophylline) -Enteric pill coatings can be worn off by hot beverages, ETOH, or milk -Important to establish patient's use of herbals because many have harmful SEs

Down Syndrome

-Characterized by presence of extra chromosome #21 (trisomy 21) -Distinctive flattened facial features, eyelid folds & slanted eyes, relatively small mouth with obtruding tongue, short neck, & diminutive hands with short inward curving 5th fingers -Risk factors: advanced maternal age (35 or older), few children in younger women -At birth, may have comorbid conditions such as heart defects or esophageal atresia (both usually corrected later with surgery) -Children: prone to frequent resp. & ear infections to vision & hearing problems -All have some degree of intellectual disability & some exhibit autistic along with other behaviors -Fertility generally absent in males & depressed in females, Alzheimer's disease & death are likely at relatively young age -Developmental therapy can be very productive

Metabolic Syndrome (MetSyn)

-Cluster of abnormalities: including hyperglycemia or insulin resistance, HTN, dyslipidemia, & obesity -Diagnostic criteria: presence of at least 3 of the following-abdominal obesity (waistline >40 or 35 inches), triglyceride >/= 150mg/dl, HDL levels < 40 or 50 mg/dl, BP of >/=130/85, or FSBS >/= 110 mg/dl Diagnoses, interventions, & goals -Diagnoses: decreased cardiac output, risk of infection, ineffective tissue perfusion, & risk of peripheral neurovascular dysfunction -Interventions: electrolyte & fluid management (increase cardiac output & improve renal function); immunization, vaccination, infection control, nutritional support (decrease infection risk); exercise (reduce peripheral neurovascular dysfunction) -At risk for activity intolerance, falls, unsafe health behavior, or ineffective coping; caregivers: risk for role strain; nurse's role to educate patient about disease & its management

Fragile X syndrome

-Common, often misdiagnosed genetic disorder associated w/ intellectual disability & communication & behavioral problems -Genetic mechanism is mutation in the fragile X intellectual disability gene 1 (FMR1): causes break in X chromosome -Generally seen in males -Physical features: long & narrow faces, ears that stick out & enlarged testicles; hyperextensible finger joints, flat feet, high arched palate, & mitral valve prolapse -Developmental problems: Males-poor eye contact, inappropriate repetitive responses, Females-mild cognitive or behavioral issues -Comorbid autism is prevalent -Dx: genetic testing -Can show improvement with early intercession & special education & speech rehab but often require some degree of custodial supervision

Perception

-Complex process involving observation, integration, & understanding of stimuli; different types of stimuli are processed in either R or L parietal lobe of cerebral cortex; for example, spatial & textural information is processed in R lobe, whereas reading & writing are understood through processing in L lobe -Many perception defects are associated w/ brain injuries; problems r/t body image or arrangement are common, including somatognosia (ignorance of one's own body parts & structure), inability to discriminate between L & R, visual spatial neglect (lack of response on affected side), anosognosia (denial of their paralysis), & finger agnosia (inability to distinguish specific fingers) -Various types of spatial relation disorders are also prevalent, such as problems distinguishing distances, distinguishing an object from its background, or distinguishing similar forms; agnosia (partial or total loss of recognition of familiar objects) & apraxia (incapacity to perform complex movements) are also perception problems Management of Perception Deficits -Senorimotor approach, which attempts to organize thought pattern by controlling sensory stimulation & the desired motor response -Functional approach, uses repetition of tasks to foster relearning -Another general method utilized is to make connection between similar applications in slightly different tasks, known as transfer of training; specific defects call for special types of management as well; for example, those w/ visual spatial neglect most often are unaware of their L side; this means that the nurse's job is to modify the milieu & increase patients' awareness of environment on that side through techniques that stimulate their sense there -Objects may need to be tagged for people w/ spatial relation disorders; other senses may need to be incorporated into ID of objects for patients w/ agnosia

Musculoskeletal System

-Contains over half of body weight, consists of bones, cartilage, joints, tendons, fascia, bursa, & skeletal muscles; bone is hard part of skeleton that provides structural framework to support body weight & shields vital organs, produce red blood cells & require calcium & vitamin D for support; cartilage is strong elastic tissue composed of fibers -Joints are junctions between bones; contain varying amounts & types of cartilage & ligaments & synovial fluid & determine ROM; ligaments are relatively tough tissues that connect muscles to bones -Muscles, nerves, & blood vessels are also encased by fibrous tissues called fascia; pouches containing connective tissue & synovial fluid provide cushioning & called bursa; skeletal muscle is type of fibrous tissue capable of contraction & extension through unique organization of threadlike myofibrils & fluid sarcoplasm

Micturition

-Controlled by pons (in brain) -Begins when bladder is filled w/urine via kidneys & ureters; urine is stored in bladder until a threshold volume (200-300mls) is reached; in this filling stage, pressure builds up & continence is maintained by sympathetic control mechanisms such as release of alpha-adrenergic neurotransmitter norepinephrine (contracts internal sphincter) & beta receptors that depress contraction of detrusor muscle -Proceeds when pressure increases & feeling of fullness is achieved through parasympathetic release of cholinergic neurotransmitter acetylcholine at bladder base; bladder neck opens & bladder contracts; acetylcholine also released through somatic innervation @ external sphincter; emptying or voiding occurs through urethra Nervous System Control -Processes of micturition & continence maintenance primarily controlled by messages to cerebral cortex region as well as other central nervous system centers in thalamus & in basal ganglia -Patients w/ CVA, brain trauma, or tumor, multiple sclerosis, or dementia have cerebral cortex damage -Those with Parkinson's have brainstem injuries & some strokes occur there as well; spinal cord damage can cause paraplegia & MS -Lower spinal injuries or tumors in S2 to S4 sacral region can cause condition called sacral bladder & even some peripheral neuropathies (like those caused by DM) that can affect efferent control of micturition -Continence also controlled by complex reflex arc in which brainstem centers, notably the pons, synchronize urethral sphincter relaxation & detrusor muscle contraction Changes over a Lifespan -Infants do not have a fully developed CNS; their voiding cycle can't be voluntarily controlled & occurs entirely through activation of complex voiding arc -Between ages 2-3, CNS matures & child can eventually voluntarily control reflex arc & when they void -Pubertal maturational changes strengthen pelvic muscles for further control; prostate gland grows (boy) & estrogen is released (girl); pelvic floor can be briefly or permanently weakened in adult women by childbirth -Prostate gland continues to grow in adulthood especially when middle age is reached, which augments urethral resistance & can enlarge/stress bladder causing urine retention -Estrogen is depressed after menopause, which suppresses urethral resistance & can lead to withering of pelvic floor structures, propensity to infection, & incontinence -Some older adults prone to overactive bladder; may results when detrusor contracts too often involuntarily or when increased urge to void occurs d/t late realization of desire to void

Coping with Health Issues card #1

-Coping: process of dealing w/ difficult or situations, manner in which people cope is dependent on life experiences or biography as well as other factors; central to ability to cope w/ health issues is concept of wellness or physical, mental, emotional & spiritual well-being -Physical state alone does not necessarily determine wellness; other attitudes contribute to wellness as well, such as personal integrity, feeling of control, & comfort, a comparative measure of contentment; personal integrity is influenced by other perceptions such as degree of vulnerability or susceptibility to potentially harmful situations & stressors -Stress can be caused by psychological factors, such as past loss, impending threats, or challenges or difficulties that need to be dealt with; those in dire situations w/o choices tend to expend energy just holding themselves together or enduring; if reflection & assessment are added, then person is experiencing suffering; constant sadness=chronic sorrow, transition is evolution from one state through a neural period into another status -Individuals must cognitively appraise situation before they can decide how to cope w/ it; this appraisal includes primary option as to potential stress evoked, a secondary appraisal about possible options, & if there is additional information, possibly reappraisal -They shape their assessments in light of environmental factors such as pressures, constraints, & opportunities in context of cultural perceptions; they tend to interject personal variables as well such as goals, beliefs, & personal situation; people have coping styles as well -Some use emotion-based approach while others are more reflective or problem solving oriented, degree of stress invoked by particular situation or event depends on their sense of life as meaningful; meaning can be global, the person's long-term beliefs & goals, or situational, shaded by immediate events-thus someone's coping mechanisms are extremely personal

Altered glycemia & Diabetes Mellitus

-DM type 1 & 2 are defects of endocrine & metabolic regulation -Type #1: d/t destruction or a flaw in pancreatic beta cells (which produce insulin) -Type #2: insulin resistance & usually obesity -Untreated DM results in elevated blood glucose levels (hyperglycemia) -S/S of hyperglycemia: frequent urination, hunger or thirst, persistent infections, deficient wound healing, fatigue, weight loss, dry eyes, vision changes, impotence -Management: keep BS 80-120 before eating, <140 after eating, & <180 @ HS through weight management, exercise, meal planning, insulin use, self monitoring w/ HbA1C or other lab tests -Complications: acute DKA, HHMS, or chronic vascular problems -Also can get hypoglycemia (low BS) evidenced by confusion or hunger; give carbs w/ protein

Motor Stretch Reflexes

-Deep tendon reflexes (DTRs) should be assessed measure functional responses that are controlled by different portions of CNS -Tendons over specific muscle groups are struck & then reflexes are evaluated in terms of reflex activity level, symmetry of reflex, presence of abnormal reactions, & contraction -7 motor stretch reflexes that are evaluated; biceps, brachioradial, & triceps reflexes evaluate responses from upper C5-C6 & C5-C8 (triceps regions of spinal care; patellar or knee jerk reflex measures lower L2-L4 functions & Achilles or ankle reflex evaluates even lower S1-S2 centers -Abdominal reflex lowers at lower thoracic cord centers & can be used to dx MS; plantar or Babinski reflex, in which toes should curl up when the sole of foot is struck, is measurement of upper motor neuron injury in anyone > 1 year

Obesity

-Defined by body mass index (BMI) --Calculated by weight in kg/(height in meters)2 -BMI ranges --Underweight-BMI <18.5 --Normal-BMI 18.5 to 24.9 --Overweight-BMI 25 to 29.9 --Obese class I-BMI 30 to 34.9 --Obese class II-BMI 35 to 39.9 --Obese class III-BMI >/= 40 -Anyone in overweight or obese class at increased risk for health problems -If overweight w/waist >40 inches (men) or >35 inches (women) are more at risk than BMI alone would indicate -Tx: weight reduction, physical activity, reduction in caloric intake

Constipation

-Definition: difficulty w/ defecation d/t longer transit time & greater water removal in large intestine yielding hard & dry fecal waste; also been defined as presence of 2 or more of following characteristics for at least 12 weeks out of last year: <3 BMs/wk or presence of at 25% of time straining upon defecation, lumpy or dense stools, sensation of unfinished evacuation, and/or need for digital removal -Neurological diseases (diabetic neuropathy, Parkinson's disease, & SCIs) can produce constipation by causing motility problems and/or disordered contractions -People who are stressed/ depressed often lack appetite & have slower transport; poor hydration, diets w/ little fiber, & certain meds; if pt curbs defecation reflex or has inferior toileting procedures, may become constipated d/t increased water removal in rectum Medications Causing Constipation -Those w/ anticholinergic properties, including antihistamines, tricyclic antidepressants, antispasmodics, & antipsychotics -CNS depressants: tx convulsions or Parkinson's disease, narcotic analgesics of opiate or barbiturate variety, & parasympatholytics -Calcium channels or beta-adrenergic drugs, dysrhythmias or diuresis meds -Vinca alkaloids (tx cancer), antacids (contain cations), NSAIDs (naproxen), certain laxatives

Multiple sclerosis (MS)

-Demyelination of neuronal axons in CNS; mediated by immune & inflammatory responses but root cause is unknown; as demyelination proceeds, axon breaks apart & loses functionality -Impairments: problems with vision & eye movement, coordination, manner of walking, spasticity, elimation, swallowing, & other motor skills; most common complaint is genral fatigue -May be relapsing-remitting (no progression), primary or secondary progressive, or progressive relapsing -Lesions or plaques on 2 or more CNS regions are diagnostic, most also have abnl brain MRI scans, lumbar scan is also done for exclusion purposes -Interventions: various forms of interferon (an antiviral & antineoplastic agent) including beta 1-a (Avonex or Rebif) to slow progression and interferon beta 1-B (Betaseron) to moderate episode frequency; antineoplastic agent glatiramer acetate used for less severe relapsing-remitting form, monoclonal antibody being developed; corticosteroids or immunomodulators used to manage MS episodes

Bronchopulmonary dysplasia (BPD)

-Disorder that often requires ped rehab nursing -Chronic lung disease in which lung tissue is damaged during birth of premature infant at risk for resp. distress syndrome -Generally initiated by use of too much IV fluids, high O2 levels, or mechanical ventilation -Focus is on stabilization of resp. status to establish airway patency & proper gas exchange through supplying supplemental O2 (given through NC, vent, or trach -If have ineffective feeding patterns-need to have tube feeds & swallowing therapy; watch to ward off malnutrition -Should be vaccinated against RSV; at risk for delayed growth & development, behavioral problems & injuries

Ear & Hearing card #1

-Divided into 3 sections: --External auditory canal: consists of outer ear, approximately 1 inch long auditory canal & tympanic membrane (gathers sound eaves) --Middle ear: air filled, is narrow section that primarily transfers pressure variations; eustachian tube connects this part to pharynx as well for pressure equalization; after traveling through oval window, pressure waves are received by inner & ultimately transferred to a bony portion called the cochlea; organ of Corti is hearing sensory organ within cochlea-contains hair cells that are shifted by sounds waves & converted into neural responses transmitted via 8th or acoustic nerve to brain --Inner ear: preserves balance & equilibrium; has bony parts called vestibule & 3 semicircular canals containing nerve receptors as well as membranous portions called utricle & saccule Hearing Assessment -Should be completed by rehab nurse upon initial pt contact; external ear should be examined visually & palpated for tenderness, & ear canal should be inspected using otoscope; in addition, hearing acuity should be assessed using one or more of the following tests; earphones can be used to test air conduction of sound -Several techniques use tuning fork to test conduction sound; techniques used are direct stimulus of inner ear, the Weber's test (placing tuning fork at midline to test for symmetry of response), or Rinne's test (placing tuning fork near mastoid process & pinna to differentiate between bone & air conduction, which is usually greater) -Audiometry: uses specific tones frequencies, speech audiometry evaluates percentage of specific two-syllable words understood; tympanometry quantifies the energy absorbed by middle ear when sound is introduced into canal; other tests include acoustic reflex testing, holocaustic emissions, & auditory brainstems response (which examines electric waveforms) Types of Hearing Loss (2) -1st: conductive, meaning lack of proper sound wave transmission; otitis media, ear infection & associated inflammation, is greatest cause of conductive hearing loss, & smoking is another risk factor -2nd: sensorineural is less common but more critical; about 0.1% of population is born w/ this type of loss or deafness d/t sensory hair cell or neural defects of spinal ganglion cells; can also be acquired through certain infections, in conjunction w/ autoimmune diseases, through use of potentially ototoxic drugs (cisplatin & aminoglycosides), exposure to loud sounds, head trauma, spongy bone growth in inner ear (otosclerosis) or presence of benign tumor (acoustic neuroma); latter 2 conditions can precipitate balance problems & possibly other problems in addition to hearing loss

Urinary Tract

-Divided into upper & lower zones -Upper consists of kidneys (separate out waste products from blood & produce urine), ureters (muscular cylinders that empty urine from kidneys into bladder) -Lower consists of bladder & urethra -Bladder: hollow container for urine comprised of 2 smooth autonomic muscles: detrusor muscle, makes up bladder body, & trigone at bottom -Below bladder base is bladder neck, contains various muscular structures that form internal sphincter & voluntarily controlled external sphincter -Urethra: tube for discharging urine that originates in bladder neck; shorter in women, accounting for higher rates of incontinence in women than men -While strictly part of the urinary tract, pelvic floor muscles (women) & prostate gland (men) also control urethra contraction

Nursing Assessment for Apprehension & Expression of Pragmatics

-Examiner should observe pt's speech in terms if use of affective prosodia & expression of suitable emotion & attitudes; should also test ability to recognize nuances by delivering seemingly neutral declarative sentence in a particular tone & seeing if they can repeat it using same tone -Stand outside of visual field while delivering same type of sentence to see if they can ID voice affect utilized; ability to understand visual gestures can be evaluated by making a statement in a neural tone of voice while conveying emotion through use of facial gestures, & then asking pt to categorize or describe suggested emotion

Pain card #1

-Feeling of discomfort in response to tissue or organ damage; when damage occurs, pain impulses are carried through afferent fibers to substantia gelatinosa in lateral spinothalamic tract of spinal cord -Current hypothesis is gate-control theory espoused by Melzack; according to this theory, amount of perceived pain is dependent on distribution of fiber types stimulated; small a-delta afferent fibers are generally responsible for pain, whereas larger fibers in same area carry sensations for touch, temperature, & pressure; therefore, simultaneous use of these sensations can lessen pain -Pain perception is also moderated by descending motor fibers originating in cerebral cortex; also influenced to a certain degree by cultural inferences & previous experience; pain is a defense mechanism, and its absence, such as when pain receptors are destroyed in leprosy, can be dangerous Assessment Tools for Evaluation -Several standardized pain intensity rating scales -One is categoric scale in which they are asked to rate pain on scale from 0 (no pain) to 5 (excruciating pain); others are numeric scale, which uses linear scale from 0 (no pain) to 10 (worst pain imaginable), & visual analog scale, another linear but non-numeric tool in which patient picks a point between no pain & worst possible pain -There are pain questionnaires available; for questioning pt, mnemonic devices have been developed as well; important to cover topics of what provokes or palliates pain, quality/type of pain. presence of radiation & region affected, severity, & timing of pain occurrence (in other words, PQRST) -In children, different scales such as Wong-Baker Faces (6 faces from 0-5 are used to describe pain level w/ feelings-sad/happy) -In young children who can't verbalized pain levels, use FLACC scale (5 parameters 0-10, face, legs, activity, crying, & consolability)

Reproduction Issues r/t Traumatic Injuries or Chronic Illnesses

-Female fertility is generally affected only transiently; women w/ SCI can conceive & deliver babies, but may have problems during L/D d/t autonomic dysreflexia; these are usually addressed through use of epidural anesthetics & BP meds -Men can experience infertility d/t erectile or ejaculation malfunctions, poor thermoregulation to testicle area, or infections or hormonal imbalances; latter can effect female fertility also -Major issues are birth control information dissemination & usage; disabled individuals, especially childbearing age) should be informed of options

Swallowing card #1

-Food is ingested through oral cavity (lips, hard & soft palate of maxilla, mandible, several arches, tonsils, salivary glands, tongue, teeth, gums) -Various types of sensory cells (mechanoreceptive, thermoreceptive, & chemoreceptive) that innervate oral cavity & promote swallowing or deglutition -Muscular tube between soft palate & esophagus is pharynx; comprised of 3 parts: nasopharynx above soft palate, oropharynx at back of mouth, & hypopharynx going below esophagus; muscular fibers aid food propulsion in correct direction -Esophagus: bare muscular tube with sphincters at each end; upper esophageal sphincter (UES) prevents air from entering stomach & decreases gastric reflex; cricopharyngeal muscle prevents air from entering esophagus -Larynx (voice box): cartilaginous structure beginning w/ epiglottis at tongue base. epiglottis moves during swallowing to protect trachea Cranial Nerves -During swallowing (deglutition), 6 cranial nerves carry info from involved structures to brain for assimlilation & coordination -1st 3 cervical nerves also implicated in eating & deglutition; trigeminal (V) nerve is associated w/ both motor control of mandibular muscles & sensory functions in both jaws; facial (VII) nerve controls motor functions in salivary glands & those involving facial expression. also associated w/ frontal taste buds; glossopharyngeal (IX) nerve regulates stylopharyngeus muscle, posterior taste buds, & feeling in soft palate -Cranial nerve (X) vagus, controls sensory responses in membrane of larynx & pharynx -Last 2 nerves, spinal asscessory (XI) & hypoglossal (XII), regulate motor functions of sternocleidomastoid muscle & intrinsic tongue, respectively

Gait Abnormalities

-Gait is manner of walking; can be effected by various neuromuscular alterations; physical exam should document gait pattern, including use of arms, balance, ability to turn, & presence of involuntary motions -One neuromuscular disease that causes abnormal gait is hemiplegia or partial or total inability to move one side of body; generally occurs as a result of brain damage -Individuals w/ hemiplegia have stiff gait & slouch to one side; people w/ Parkinson's disease sway or wobble when they walk, take small steps, & keep their arms back instead of using them -People w/ MS or cerebral palsy take very slow & scissor-like steps; other gait abnormalities indicative of problems include climbing motions & moving from side to side

Communication Disorders card #1

-General nursing dx for patient w/ communication problems is impaired verbal communication according to NANDA, desired nursing outcome is achievement of effective communication, both receptive & expressive; achievement of this goal can be furthered by interventions such as providing a therapeutic & supportive environment to overcome speech deficit & managing pt's environment & energy levels -NANDA also recognizes 4 other possible nursing diagnoses: (1) impaired written, emotional, and/or gestural communication, w/ many of the same interventions & goals as impaired verbal communication, (2) impaired social interaction, where nurse's role is socialization enhancement, (3) anxiety, where main goal is to reduce anxiety in order to allow pt to cope & relax, & (4) deficient knowledge, where nurse serves primarily to educated pt & family about procedures & disease process Therapeutic Rehab Environment -One that is quiet, tranquil, unhurried, & uncluttered but not completely isolated; main goal is to provide setting that makes attempts at communication less stressful; inherent in this concept is ID stressors & their elimination -For those whose comprehension is relatively intact but who may have trouble w/ expression, clinician's role is to provide a pleasant environment & many opportunities for social interactions such as group activities -Nurse should praise individual for any communication attempts & utilize all means of communication, such as gestures & sign language, in addition to speech; for patients who have comprehension problems, room should be quiet as possible; for these patients, boundaries need to be set for amount & duration of communication & group activities to avoid fatigue; any intervention that creates anxiety or stress should be stopped

Altered Muscle Movement

-Generally involuntary actions; often associated w/ specific motor defects; tremors are slight shaking or trembling movements that are usually rhythmic & unplanned; often found in individuals w/ Parkinson's disease as well as w/senility, exposure to toxic metals or psychogenic drugs, & injuries to cerebellum or brainstem -Chorea is arrhythmic, erratic, & forceful unplanned movements; athetoses are slow & twisting involuntary movements that occur in distal limbs; both chorea & athetoses can occur w/ use of dopamine-related drugs, and chorea can occur in diseases involving increased amounts of or sensitivity to dopamine, such as in Huntington's chorea -Ballism: very violent & erratic throwing around of head or arms; usually result of damage to basal ganglion

Muscle Contraction

-Golgi tendon receptors & muscle spindles are stretch receptors; muscle is made up primarily of bundle of muscle fibers; at end, muscle is connected to tendon as well as Golgi tendon organs, which are basically composed of sensory dendrites & collagen -When muscle contracts, Golgi tendon receptors are activated & send signals to inhibitory interneurons in CNS that trigger relaxation of muscle -Conversely, muscle spindles contain specialized muscle fibers called intrafusal fibers, which send message to CNS when a muscle is stretched that elicit shortening or contracting muscle reflexes -Initially during contraction, nerve signal triggers liberation of neurotransmitter acetylcholine, which transverses neuromuscular junction & binds to receptors on muscle fiber; activated acetylcholine receptors transmit impulses in muscle & ultimately to sarcoplasmic reticulum (SR) where calcium ions (Ca++) are discharged into sarcoplasm -There, calcium ions bind troponin molecules in thin myofilaments; resultant tropomyosin causes myofilaments to move & uncover active sites on actin molecules; muscle protein called myosin builds cross bridges in thick myofilaments, binds to actin, & draws thinner filaments closer to center of muscle fiber, using adenosine triphosphate (ATP) as energy source -Eventually, thin & thick filaments slide over each other to cause shortening of muscle fiber; relaxation occurs when calcium starts being pumped back into sacs of SR & is removed from troponin molecules; actin is blocked & can't bind to myosin bridges, resulting in return to normal resting state

Physical Assessment of Patients w/ Nourishment Issues

-Head & neck examined for facial & internal symmetry, moisture or drooling, presence of gashes from biting, head control when seated, & dentition; cranial nerves should each be tested for functionality -Both glossopharyngeal (IX) & vagus (X) may be evaluated by looking for a rising soft palate & its flap (uvula) when pt says "ah"; pressing tongue depressor on latter can test gag reflex -Trigeminal (V) nerve assessed for muscular & sensory responses to application of resistance during clenching or palpation & ID of dull vs sharp feelings in facial area - Facial (VII) nerve evaluated for motor & sensory functions by observing facial movements & testing ability to ID sweet & salty tastes on tongue -Hypoglossal (XII) nerve assessed by examining tongue inside & outside of mouth -Spinal (XI) assessed by having pt raise their shoulders & move head against resistance -Notations are made r/t abnl reflex patterns, voice tone, swallowing of H2O, & muscular functions

Healing & Forgiveness

-Healing: internal & conscious process of releasing negative attitudes & patterns & reestablishment of feeling of wholeness; independent of process of curing or physiological tx of disease; nurse can play important role in healing process -One crucial component toward healing is usually forgiveness, act of pardoning oneself & others, & also asking for forgiveness from God or others; generally, people can't move on unless they have embraced forgiveness; another element, often facilitated through forgiveness, is development of a feeling of serenity or inner peace

Nursing assessment of neurological impairment

-Health history: med use, prior hospitalizations & surgical procedures, concomitant disease states, history of exposure to toxic substances, presence of risk factors, patient's environment, & available support system -Patterns r/t neuro issues: abnl urinary & bowel elimation, ingestion problems, difficulty sleeping, cognitive or sensory changes, sexual problems, muscle weakness or poor coordination -Document neuro issues impact on concept of self, relationships, ability to cope -Imaging options: CT, MRI, PET scans -Tests: Cerebral angiography w/contrast, electromyography, nerve conduction analyses, spinal taps

Huntington's disease

-Hereditary degenerative neuromuscular disorder presents usually in middle age -Caused by accumulation of amino acid glutamine in brain where it kills cells -Brain centers related to movement, perception & memory, balance & coordination are affected -Involuntary, strange movements develop d/t increased levels of inhibitory neurotransmitter dopamine & decreased levels of acetylcholine -Eventually all muscle actions become uncontrolled & they develop dementia -Diagnostic tests: neuro exam, imaging (CT and MRI would show brain shrinkage), genetic predisposition through family history & genetic studies to look for abnl gene on chromosome #4

Holism & Spirituality card #1

-Holism: theory of health treatment that incorporates physical, psychological, & social aspects to achieve health & well-being -Spirituality: inner awareness & a relationship w/ a higher force, this force can be defined by religion, but this is not a prerequisite for spirituality, which is unique to each individual; can be part of a holistic approach -Other concepts r/t spirituality include soul & spirit; soul refers to nonphysical aspects of a person that shape their relationships & emotions, & includes elements such as memory, understanding, & will -Some religions like Christianity contend that soul continues after death, spirit is intangible life force of individual; when pt lose bond to higher force they normally embrace, they experience spiritual crisis & associated changes detrimental to well-being Spiritual Roles for Nurse -Can intervene in ways that incorporate a pt's spiritual beliefs w/o revealing or abdicating own value system, reliance on religion or spirituality tends to increase greatly during times of illness, nurse needs to understand that suffering is personal & shaped to an extent by religious or spiritual beliefs -Some will down play severity of suffering while others will regard it as punishment for their sins, nursing interventions mainly consolation & counseling of pt in order to build trust, bolster hope, & foster independence -Presencing (just being there for support or through touch) is actually primary spiritual role of nurse, spiritual team members such as chaplain can also be enlisted, there are also parish nurses who work in community primarily through some established religious organization; studies have shown that embracing spirituality during chronic illness helps patient to cope

Hope Instillation, Complex Relationship Building, & Support System Enhancement

-Hope Instillation: a process of making it easier for a person to develop a positive outlook, it is an individualized process that rehab nurse can nurture through emphasis on possibilities not limitations, encouragement of every minor success, & elimination of uncertainties -Complex Relationship Building: refers to development of mutually beneficial relationship between pt who has trouble relating & health care workers, this is generally a protracted process of establishing rapport -Support System Enhancement: the enrichment of pt's life through interactions w/ family, friends, & society; nurse can encourage support system enhancement by having pt's friends visit them as soon as possible & enrolling pt in peer support &/or self-help groups

Safety Bar Installation

-If need for balance when using the toilet, several possible configurations; bar can be installed diagonally at 45-degree angle on wall near strong hand; raised toilet seat may be used to facilitate use; typically a 33 inch bar is used (are other lengths); lower & upper ends of bar are about 35-60 inches from floor, respectively, & bar projects 2-4 inches from wall -There are a number of primarily right angle configurations for bathtub or shower grab bars commercially available as well; alternatively a one-piece right angle bar can be mounted from a point on person's stronger side; typical height for right angle bar is 31 inches; various transfer boards & bathtub seats are also sold

Sensory Assessment Techniques

-If they demonstrate sensory impairment, there are a number of assessment techniques that can be utilized; patient always closes their eyes during these tests --Tactile: touch patient w/ cotton swab at various points & asking when patient feels prodding-this can separate normal from abnormal tactile sensation --Temperature: assessed by placing warm or cold glasses against patient's skin --Vibratory: placing vibrating tuning fork against limb --Proprioception: moving one of fingers or toes & asking pt to ID digit --Pain discrimination: pricking w/ open safety pin & having them describe location & feeling (sharp or dull) of prick; also test called two-point discrimination in 2 skin pricks (in this case usually w/ toothpicks) are done, & individual must determine distance between them

Traumatic Brain Injury (TBI)

-Impairs many types of motor sensory functions -Can occur through traumatic events (fall, MVA, sports injury, child abuse) -Type & seriousness dependent on location & nature of brain lesion -Children: disturbed though processes, urinary & bowel incontinence, various types of sensory deficits, impaired swallowing., speech defects, impaired physical mobility, & possibly delayed growth & development -Assess level of cognitive functioning with Rancho Los Amigos Level of Cognitive Function Scale (indicates type of intervention needed)-levels I-III=simple functions (elimination & feeding) while IV or higher=promote school & community reintegration

Sense of Smell

-In nose epithelium, odors are converted into chemicals that arouse olfactory receptors to cilia of nasal passages; sensory responses are then transported through olfactory bulb & tract to portions of cerebral cortex w/o thalamic involvement -2 separate smell pathways are generated in brain, one involved w/ perception of odor & smell & the other r/t memory of emotional response to smell; some loss of sense of smell is often found in geriatric patients, but can also be observed along w/ cognitive impairment, strokes, vitamin deficiencies, radiation, certain drugs, & any untoward stimulus of nasal cavity -Olfactory sensation can be assessed bu having them shut their eyes & smell ampoules of coffee, peppermint oil, & lemon juice to see if patient can distinguish them; olfactory problems can lead to weight issues, which should be monitored & an inability to sense dangerous situations such as gas leaks or fires

Assessment of Sexual Function

-Includes sexual history, sexual physical exam, & diagnostic tests; purpose of sexual history is detection of sexual problems or erroneous beliefs; should include elements such as medical history of any relevant neurological issues, STDs, & other related disorders (HTN, endocrine problems, or DM); should address current med usage, sexual functions prior to current problem, physical problems that could influence sexual function such as paralysis & incontinence, & gender-specific parameters r/t sexual response -Physical examination ought to include inspection of external genitalia, including neuro assessment of rectal sphincter tone, pelvic & breast exams (women) & squeezing of testicles to look for pain (indicative of psychogenic erections) -STDs diagnosed through urine cultures or pap smears; neurological capabilities in genital area can be appraised using urodynamic testing & in men nocturnal penile tumescence testing or intracavernosal injection of drugs to see if erection can be induced

Methods to Learn Language

-Initially limiting & reinforcing vocabulary taught is helpful for teaching child language; relating number of words to a specific activity that child performs is useful; making child verbally express word rather then gesture before action is helpful -Clinician or other adult should always speak at level a bit higher then that of child & show child ways to extend what they have already said; emphasis should be on meaning, not linguistics -Children (or adults) who can't read or write are said to have alexia or agraphia respectively, these individuals are generally taught in traditional classroom setting supplemented w/ homework projects

Advanced Language Skills

-Involve integration of several cognitive networks; attention networks control patterns of communication, attention contains 2 components: a selective orientation physically or mentally, which is mediated by thalami: & detachment from tasks, which is controlled by R side parietal region -There is another network r/t declarative memory or personal history; this too has 2 sets of connections: domain-independent or short-term memory centered in L hippocampus & associated temporal regions, & domain specific or long-term memory, stored in various areas of parietal, temporal, & occipital lobes -Both hemispheres participate in long-term memory, w/ L primarily involved w/ language & mathematics & the right w/ more experiential features; also executive attention networks involved w/ vigilance, detection, & working memory mainly controlled by R frontal areas & brainstem's locus ceruleus, the anterior cingulated cortex & basal ganglia, & anterior cingulate & lateral regions of frontal lobes respectively Formulation of Concepts -Concept formulation & storage is mediated by memory networks; concept formation requires categorization & analysis of relationships, logical reasoning, & ability to abstract from information gleaned; executive attention networks of detection & working memory are accessed for concept formulation rather than new stimuli -Prefrontal cortex regions are important for advanced language skills such as concept formulation, w/L one r/t learning & R prefrontal cortex involved w/ recall -Young children have not developed enough networks to analyze relationships & form concepts, but concept formation & problem solving usually begins prior to school age & continues throughout life unless impaired

Isotonic, Isometric, & Isokinetic Muscle Movements

-Isotonic movements occur when muscle is maintained at constant tension, but muscle length is changed; 2 types of movements, those in which muscle is lengthened (eccentric) & those where muscle is shortened (concentric); related term is muscle tone or firmness while relaxed -Isometric movements change tension of muscle while maintaining it at constant length, such movement may involve pulling against force without shortening muscle, no actual body movement occurs during isometric exercise -Isokinetic: individual's complete ROM is utilized through intervention w/ specialized machinery

Renal system & disease card #1

-Kidney is divided into outer cortical & inner meduallary regions -10^6 nephrons or functional units are in each kidney as well as the glomerulus & various tubules -Ureter carries urine from kidney to bladder -Blood vessels connect kidney to vascular circulation -Kidneys maintain homeostasis,acid-base equilibrium, & electrolyte and fluid balance --Also remove waste products & regulate certain hormones & other bodily substances -With normal kidney function: glomerulus filters out cells & other bodily substances; also filters out cells & protein to give an isotonic plasma product -Creatinine is filtered at Bowman's capsule; ultrafiltrate processing starts in proximal convoluted tubule, which extracts electrolytes & nutrients & returns them to general circulation -Loop of Henle reabsorbs sodium chloride & dilutes urine; distal convoluted tuble then reabsorbs H2O & NA in response to renin (enzyme that breaks down proteins & regulate BP) & angiogenesis (hormone that raises BP) -At end is collecting duct or tubule where antidiuretic hormone (ADH) starts water removal Chronic kidney disease (CKD) -Majority of CKD & end-stage renal disease (ESRD) are caused by DM, but HTN & glomerulonephritis are significant contributors -5 stages of CKD defined by creatinine clearance: >90, 60-89, 30-59, 15-29, & <10-15 ml/minute for stages 1-5 respectively --Stage I: disease is monitored --Stage II: BP needs to be controlled & urine proteins are quantified --Stage III: referred to nephrologist --Stage IV: anemia management, BP control, & prepared for dialysis or kidney transplant --Stage V: ESRD (Medicare), normal renal functions are shut done, dialysis is life sustaining; children should receive kidney transplants if possible

Altered Muscle Tone

-Lack of muscle tone is either hypotone or flaccidity; this condition can lead to lack of use & muscle atrophy -Increased muscle tone is called hypertone or spasticity; hypertonicity can result in involuntary spasms in muscles often associated w/ gait defects or inability to move parts of body; resist stretching & are often found in extremities -Clonus or clonic spasm: term for rapid muscle contractions & relaxations usually linked to epileptic seizures; clonus arises from uninterrupted reflex arcing d/t UMN lesions -Rigidity: refers to muscles that are stiff & unbendable as result of augmented tension between opposing contracting (agonist) & relaxing (antagonist) muscles; rigidity can result in poor mobility & muscle function

Cardiac rehabilitation card #1

-Long-term goal: reversing or stabilizing atherosclerosis Qualifications for care professionals -Cardiac rehab programs usually comprehensive & long-lasting --Include medical evaluation, exercise regimens, risk factor adjustment, education, & counseling -Health care team: Supervisory MD, RN, program coordinator (another RN or other allied health professional), consulants (dietitian, cardiologist, PT staff) -Minimum qualifications for all team members as Bachelor's degree in appropriate field, training & experience in CV rehab, knowledge of areas such as exercise physiology & nutrition, and BLS course completion; also prefers ACLS and professional certifications Ideal Candidates -Candidate pool enlarged d/t changing views on treatment -Best candidates: MI, stable angina, CABG, PTCA, & CHF; participation also affected by presence of risk factors & comorbidities

Alleviation of Constipation or Diarrhea

-Main method is introduction of a high-fiber diet through use of minimally or unprocessed bran or other cereals, legumes, fruits, & leafy or root vegetables; should be started slowly to prevent abdominal pain, digestive gas, or diarrhea until suggested amount of 28-30 grams of fiber/day is achieved; recipes that include prune juice and/or bran are helpful -Must also have sufficient fluid intake & some physical activity; in general, chronic laxative use is shunned, except for cancer patients using narcotics (use senna derivatives in that case); those experiencing diarrhea may have an underlying fecal impaction in which case care is some as for constipation -Otherwise, causative agent for diarrhea needs to be ID & treated; many broad spectrum antibiotics & other drugs can cause diarrhea & should be eliminated or substituted; certain foods like yogurt, bananas, rice, & applesauce are useful; management includes fluid & electrolyte restoration as well as skin protection & cleansing

Normal changes associated with aging

-Many cardiopulmonary functions decrease (pumping force, work capacity, chest wall compliance) -At increased risk for arteriovenous blocks, arrhythmias, other CV diseases & pulmonary infections -Abnormalities: hypotension while standing, or bradycardia usually are linked to illness -Musculoskeletal issues: decreased height, poor posture, decreased mobility, rearrangement of body mass, fat, or minerals; stiff joints or muscle atrophy are disease related -Normal: diminished short-term memory, response times, or sensory reception; abnl to have decreased cerebral blood flow, balance or coordination -Bowel: saliva, gastric juices, absorption, & peristalsis all slow; gastroparesis or dysphagia are abnormal -GU: vaginal atrophy, prostate enlargement; abnl: diverticula or elevated PVR volume -Liver: functions decrease; abnl: elevated liver enzymes=chronic disease -Renal: functions & clearance rates decrease; abnl: high BUN, creatinine levels=underlying disease -Hypoglycemia, delayed skin/wound healing time, sleep problems (excessive napping)

Malnutrition & Dehydration

-Many neurological disease cause dysphagia & therefore, lack of nourishment & dehydration -Dysphagia: inability to swallow in normal manner; can cause aspiration or inhalation of fluids/food into lungs, predisposing person to aspiration pneumonia, choking, dehydration, & nutritional deficits -Many other factors r/t malnutrition: too many conflicting medications, ETOH use, poor dentition, depression, functional disability or frailty, failure to eat enough -As people age, sense of thirst is lost & also retain loss H2O in kidneys, creating propensity toward dehydration -Certain disease change appetite & nutritional intake -Stressful situations (burns, trauma) increase metabolic rate & promote nutrient loss; therefore, these people need more calories, vitamins, minerals -Elderly generally have a low basal metabolic rate, decreased glucose tolerance, excess weight -Anyone who is obese (BMI >/=30) is at increased risk for many disease states

Transferring Patients With Some Independence

-May be able to change positions by doing pivot transfer, an independent standing transfer, or by using a transfer board; In this version of the pivot transfer, brace is locked in place & then patient pivots & uses unaffected leg to supply support & balance for things such as toilet use -A hemiplegic patient can usually perform independent standing transfer from w/c close to HOB by locking chair parts & then rising to standing position by using good foot & armrest to push up; then uses unaffected arm as support on bed & takes short side steps until can sit on side of bed -Useful device for relatively independent patients is transfer board, used for bed-w/c transfers w/ both at same height; shifts buttocks on board & then uses upper limbs to help them scoot across; paraplegics w/ a lesser degree of loss of use can upper UEs for transfer assistance

Disorders & Neurological Issues Affecting Fertility

-Men w/ SCI, reduced testosterone levels d/t endocrine problems, or in some cases, alcoholism can experience decreased fertility; there are several possible factors that may act in consort; their semen volume may be low, resulting in low sperm count or mobility; the endocrine and/or neurological changes may contribute to suppressed libido, changes in secondary sex characteristics, ED, or retrograde ejaculation of semen in bladder -Female fertility can be affected by damage to endocrine system, brain injuries, or disorders that control hormones r/t ovarian function, & other reproductive problems such as polycystic ovaries or hypogonadism; can be temporarily affected by SCIs -Birth defects can caused by ETOH or certain medication use during pregnancy

Coping Enhancement

-Method of helping pt to adapt to stressors, changes, or threats to lifestyle; active listening to pt's narrative can help nurse to develop strategies for coping enhancement; strategies that have been found to be effective include those aimed at increased pt self-awareness and/or self-efficacy -Examples include didactic exercises, feedback or other behavioral techniques, counseling, telephone follow-ups by nurse, boundary setting, prioritization, detailed planning, development of negotiation skills, recognition of coping sabotage, & use of all available resources; nursing schemes can target individual or family as a whole

Serial Casting & Dynamic Splinting

-Methods for maximizing stretching, ROM, & movement in patients w/ contractures -In serial casting, a well-cushioned cast is applied to joint area in extremities right after joint has been stretched; within 2-3 days, cast is removed, skin integrity is evaluated, & another similar casting is done; process repeated for up to about 5 days -Dynamic splinting is routinely performed after orthopedic surgery, particularly to upper limbs; allows fair amount of movement while using tension to stretch the joint; usually a CPM device attached that promotes joint mobility & prevents tightening of muscles

Parkinson's disease

-More than 1 in 100 people have disease -Most cases are triggered by infection, traumatic event, medication, or chemical exposure -Underlying defect is lack of enzymes that metabolize dopamine in basal ganglia, resulting in low levels of dopamine & too much acetylcholine -Result: muscle rigidity, trembling, bradykinesia, postural problems, & dementia (sometimes), shuffling gait, sluggish & slow speech patterns, vacant facial expressions -May be caused by genetic component, free radicals may accelerate neural damage -Dx: neuro exam, PET scan, assessment of drug & toxic exposure Tx: Levodopa or carbidopa used to stimulate dopamine production; dopamine agonists such as apomorphine, rotigotine, ropinirole (CR form); MAO or monoamine oxidase B inhibitor rasagiline useful for relief from bradykinesia, tremors, & rigidity; dementia (if present) treated with acetylcholinesterase inhibitors; Cathechol O-methyltransferase (COMT) prevents levodopa breakdown & antioxidants delay disease progression

Nursing Assessment for Dysarthria & Other Language Disorders

-Most queries should be about presence of stammering, omission of certain sounds, substitution of wrong consonants, recent voice changes, & difficulties understanding child; clinician also needs to observe speech pattern during dialogue or reading aloud for types of articulation errors; they might have pt reiterate sounds that are lingual, labial, & guttural (la-la-la, me-me-me, & k-k-k respectively) -Muscle tone & movement of face, palate, & tongue should be clinically observed, & motor function tests for facial, vagus, & hypoglossal nerves should be performed -There are a number of general questions to ask parent of child w/ any language disorder, centered on timeline of speech, omissions, grammatical errors, ability to multitask, & facility in responding to questions

Intellectual/developmental disabilities card #1

-Most were institutionalized until 1970s, I/DD nursing specialty established in 1997 -Need to understand physiologic & genetic causes, appropriate meds, and relationship between I/DD & other chronic diseases; must be aware of psychosocial aspects of I/DD (difficult behavior, speech processing & other communication problems, lack of social skills, associated mental health issues, & developmental effects); should understand family dynamics & hardships that impact caregivers; must be aware of community service system -Habilitation: making the best use of abilities & maximizing facility for independent living by providing medical, psychological, learning, & family services -Rehabilitation implies a re-education process; many need both -These patients, especially children, are at higher risk for falls & other injuries; increased prevalence of heart disease in adult with Down syndrome & joint problems with patients with cerebral palsy d/t nervous system degeneration -Causes: Prenatal causes or birth defects resulting from chromosomal abnormalities, single-gene disorders, or multifactor disorders --Most widespread chromosomal disorder is Down syndrome (trisomy 21) --Most common single-gene disorder is fragile X syndrome (X-linked recessive) --Most common multifactorial syndrome is spina bifida --Prenatal causes of I/DD: infection, other diseases, drug abuse --Perinatal causes: brain anoxia d/t trauma, hemorrhaging, or infection --Postnatal causes: accidents, trauma, meningitis, cancer, & environmental toxins

Neurons

-Nerve cells; contains nerve cell or soma & 2 types of thin threadlike extensions called axons & dendrites that reach into peripheral nerves or central nervous system respectively; neurotransmitters (particularly acetylcholine) convey nerve impulses between neurons -Motor nerves form synapse w/muscles at neuromuscular junction where protein neurotransmitters are released from neuron & diffuse into muscle; at this point, they excite receptors located in muscle's plasma membrane, called sarcolemma -There are other nerve cells called glia that serve primarily as a supporting neural network; for example, schwann cells around nerve cells to form a myelin sheath in conjunction w/ proteins & fats; glia can replicate & thus, regenerate while damaged neurons can't replace themselves

Reflex Arcs

-Nerve pathway that triggers reflex action in response to sensory information; if muscle is stimulated, reflex arc is triggered in either brain or spinal cord; affected muscle releases signal to surrounding sensory neuron, which is turn transmits signal to appropriate area of spinal cord or brain where an interneuron carries information -Reflex action then stimulated by motor neuron axon carrying information to other muscle fibers; some sensory information is fed into & emerges from CNS to affect same side of body, such as 3-neuron ipsilateral reflex arc, while other times the entry & exit points are on opposite sides as in a 3-neuron contralateral reflex arc -Sensory neurons can also diverge & transmit information to several parts of CNS, resulting in more than one motor neuron response or an intersegmental reflex arc

Autism spectrum disorders

-Neurodevelopmental illnesses similar to I/DD but distinguished by impairments in interpersonal & social interaction -Much more prevalent in males then females, probably d/t genetics & other factors and is seen by age 3 -Not always seen with intellectual disability -Most common form is autistic disorder --Characterized by behavioral problems like hyperactivity, severe social interaction impairments, limited & stereotypical patterns of behavior & interest, some level of intellectual disability -Less common type is Asperger's disorder --No intellectual disability, but impaired social interactions, social & emotional isolation, patterns of repetitive & stereotypical behavior & interests -Two rare kinds of autism that have moderate to severe intellectual disability --Rett syndrome (females) --Childhood disintegrative disorder

Temperature regulation of body

-Normal body temp:96-100 degrees F -Central organ directing mechanisms to dispel or produce heat is hypothalamus; also thermoreceptors in spinal cord, abdominal organs, & skin -Hypothalamus: triggers heat production or reduction through feedback loops involved w/homeostasis (equilibrium) -TSH-RH pathway releases epinephrine to produce heat, raises basal metabolic rate, & causes vasoconstriction & glycolysis; it is turned off when heat reduction is required -SNS can either raise temp by increasing muscle tone & shivering or lower it through sweating, causing vasodilation or decreasing muscle tone Effect of certain specific conditions -Fever: occurs when hypothalamic thermostatic set point has been increased d/t pyrogens released from infectious exudates or homeostatic feedback loops have been disrupted d/t certain diseases -During acute head trauma or CVA, if hypothalamus or brainstem is damaged; then hyperthermia occurs & metabolic needs increase -SCI: lose control of vasomotor activity, including sweating mechanism; sweat is excessive & body temp management is difficult; mechanism is unclear, but also increased thermo sensitivity in patients w/demyelinating disease such as MS

Blood Pressure & HTN

-Normal individual: <120/80 -Prehypertension: 120-139 SBP/80-89 DBP -Stage I HTN: 140-159/90-99 -Stage II HTN: higher readings than Stage I -Chronic HTN: many devastating bodily effects, should be controlled through meds and/or dietary modifications (especially sodium intake) -Antihypertensive drug complication: orthostatic hypotension leading to vertigo

Maintaining Mobility in Disability Patients

-Nurse can help maintain mobility by helping ROM exercises; isotonic ROM movements can be used to help maintain flexibility, tone, strength, & functional mobility; nurse should measure angle of flexion if possible; can manipulate joint's (PROM), help perform exercises, or educate to actively carry out exercises independently -Modifications can be made in specific instances such as using unaffected extremities to aid paralyzed limbs; isometric exercises that engage patient should also be done; usually pt tenses or contracts certain muscles for 10 seconds before releasing them; typical muscle groups are abdominal, gluteal, & quadriceps -Resistive-type isometric exercises such as flexing plantar of feet against board are also recommended; any type of exercise that pt can safely do is recommended; for example, those w/ osteoporosis should not do spinal flexion while Kegel exercises & oral-facial exercises are recommended for incontinence & Parkinson's

Assessment for Aphasia

-Nurse should observe pt's speech in terms of fluency, speed, grammar, & responses; also should check ability to comprehend both verbal & written language by asking them to follow increasingly complex commands or read & follow written instructions respectively -Clinician should ask patient to name objects in room; also should test ability to repeat simple sentence; lastly, writing ability should be evaluated by having them complete 2 exercises, one to write a spontaneous idea & the other to write down a statement that has been spoken

Brain

-Part of CNS enclosed within cranium that integrates nerve signals into bodily responses; within brainstem & connected to spinal cord is reticular formation from which nerve fibers lead to various regions of cerebral cortex; entire arrangement is called reticular activating system (RAS); controls orientation, sleep, & awareness -Brainstem acts in conjunction w/ RAS to regulate circulatory, respiratory, & other functions; composed of 3 parts: midbrain (directs reflexes r/t sight, hearing & posture), pons (controls breathing patterns), & medulla oblongata (involved in similar responses) -Cerebellum: located behind brainstem; hub for control of voluntary movement, balance, spatial orientation, & memory -Frontal part is cerebrum: divided into 2 interconnected symmetrical hemispheres, each w/ 4 major lobes; various areas of cerebrum regulate cognition, motor, or sensory responses; L & R hemispheres primarily associated w/ integration of analytical & perceptive intelligence respectively, & one usually predominates

Alimentary Tract

-Passage between mouth & anus involved w/ digestion & waste elimination -Food taken in through mouth & descends through esophagus into stomach; digested as goes through stomach, duodenum, jejunum, & ileum of small intestine -Nutrients & water later absorbed as food travels through small intestine & colon (consists of cecum, ascending, transverse, descending, & sigmoid); colon consists of cecum & ascending, transverse, descending, & sigmoid colons -Completed by passage through rectum & elimination at anus -Secretory glands throughout GI tract that lubricate itself is made up of smooth muscle fiber layers under electrical & neural control Innervation of GI tract -Made up of bundles of smooth muscles that form layers; individual muscle fibers are electrically linked; electrical activity between muscle fibers produces either slow & rhythmic waves or contractions to aid mixing & transport or spikes to preserve pressure/tone -In gut wall, contained enteric or intrinsic nervous system: consists of 2 networks, an outer motor or myenteric plexus & inner sensory or submucosal plexus; former influences movement within GI tract while latter regulates GI secretions & area blood flow -Parasympathetic nerve signals from brain via vagus nerve are also transmitted to certain parts of GI tract, most notably esophagus, stomach, & pancreas (digestive & endocrine gland) to increase activity; sympathetic nerve fibers from spinal cord innervate entire tract to decrease activity within canal Functions Through GI Tract -Food chewed & somewhat broken down in oral cavity; after passing through esophagus, stomach mixes food & gastric fluids to form a semifluid (chime), stores food for latter passage, & regulates chime transfer to small intestine -Peristalsis (waves of involuntary muscle contractions propel chime through small intestine; can be enhanced after eating-which distends stomach & stimulates duodenal & gastrocolic evacuation reflexes; infectious diarrhea can also stimulates peristalsis -At end of small intestine, ileocecal valve prevents backup; last section of GI tract is large intestine, here in colon water & electrolytes are absorbed & fecal matter accumulates until expulsion -Fecal material is propelled by peristaltic type actions (haustrations) & driving movements into rectum & anal canal; as it enters rectum, sensory signals are sent to myenteric plexus to start further peristalsis & another reflex (defecation reflex) is transmitted to spinal cord & back to initiate elimination

Drugs Affecting Sexual Functioning

-Patients w/ neurological & other disorders often take meds that can affect sexual function; many drug classes suppress desire & sexual function in both sexes, including SSRIs, tranquilizers, tricyclic antidepressants, diuretics, antihistamines, analgesics (particularly narcotics), street drugs, hormones, & H2 antagonists -In med, ED can result from use of many of these; ejaculation difficulties often occur w/ tranquilizer use (diazepam), anticonvulsants (phenytoin), & hypertensive drugs (methydopa); antihypertensive drugs such as phenytoin can precipitate priapism (persistent painful erection); gynecomastia (male breast enlargement), generally caused by hormonal imbalances & also by BP drugs (methydopa) & diuretics (spironolactone-used for HTN also) -In women, spironolactone use can cause menstrual changes; another source of sexual problems is antihistamine use (can cause drowsiness & suppress vaginal lubrication) -Many drug types can impair arousal or ability to achieve orgasm

Disorders & Neurological Issues Affecting Sexual Dysfunction

-People w/ spinal cord & brain injuries, strokes, or other neurological conditions have nerve damage that can cause sexual dysfunction; MS conditions in conjunction w/ neurological issues that result in impaired mobility, such as fractures, amputations, or rheumatic disease can also make it difficult to prepare for & perform intercourse -People w/ neurological conditions usually have altered sensation patterns, which may include decreased or absent sensation in erogenous zones; libido can be suppressed d/t pain or fatigue associated w/ neurological, MS, oncological, CV, respiratory, or digestive disorders; neurological damage can lead to disinhibition & sexual addiction -Bladder or bowel incontinence associated w/ neurological deficits ( or sometimes cancer-related surgeries) can contribute to sexual dysfunction through increased probability of infection, reflexive, & unsightly odors or wetness -Diabetes, alcoholism, hormonal deficits, & neurological problems can lead to impotence & problems w/ ejaculation or orgasm (men) & inadequate vaginal lubrication d/t lack of estrogen & atrophy & possible absence of orgasm (women)

Contractures

-Permanent tightening or shortenings of body parts such as muscles; result from joint immobilization & are compounded by conditions such as plasticity, paralysis, or areas of muscle disparity; three types of muscle contractures -1st: Arthogenic: multidirectional stiffening caused by injury to cartilage, synovium, or joint capsule -2nd: Soft tissue: unidirectional loss of ROM d/t damage to periarticular, subcutaneous, or cutaneous tissues -3rd: Myogenic: when muscle fibers are replaced w/ collagen during inflammatory, neurological, or traumatic events; leave extremity in flexed position

Body Mechanics & Exercise

-Principles of body mechanics describe optimal ways of standing, moving, & lifting to prevent injury; especially important when prescribing exercise as self-care technique; at core of principles is good posture, means a straight back w/knees slightly bent, weight concentrated over one's center, & wide base of support; bending should be done from hips & knees, not back -Interactions should be performed by moving closer instead of reaching; body should not be twisted or pivoted to make a turn; lifting should be avoided & smooth pulling or pushing actions used instead; props such as mechanical lifts or carts as well as safety devices such as gait belts or transfer boards should be used; environment should be surveyed for safety hazards before movements are initiated -Injuries should be reported & treated promptly

Cerebral palsy

-Problems w/ oral preparatory phase in swallowing -May be found using Denver Developmental Screening Test (Denver II) -Condition in which some type of brain injury has occurred in utero during delivery, or shortly thereafter -Child lacks muscle control, usually manifesting as spasticity; also athetoid, ataxic, and mixed versions -May have other sensory & motor impairments as well as related issues like constipation & dental problems -Dx: within 1st year through signs such as delayed development, abnl muscle tone & reflexes & inadequate feeding -Interventions: assistive devices, ROM exercise, warm baths, relaxation modalities, surgery, drugs, feeding tools & techniques, car seats that protect head, communication devices that enhance or replace speech

Diarrhea

-Rapid passage of waste through large intestine resulting in frequent, excessive, & watery bowel movements; excessive amounts of water & electrolytes are lost, which can lead to cardiac issues, renal failure, & death -Most common cause: some type of infection in GI tract; irritates bowel & intensifies secretions & motility; also can be triggered by situations that directly supporess absorption & augment stool volume & fluid level such as lactose intolerance or taking hyperosmolar drugs -Other times, main disruption is increased motility, can be found in people w/ DM, IBS, or ulcerative colitis -Usually either acute (<month) or chronic (> month)

Guillain-Barre syndrome (GBS)

-Rare autoimmune disease affecting myelin of Schwann cells of PNS, caused by exposure to specific pathogenic bacteria or viruses such as cytomegalovirus, Epstein-Barr virus, and Mycoplasma pneumonia; antimyelin antibodies are produced & myelin is destroyed through immunologic & inflammatory processes -Symptoms: are progressive & symmetrical muscle weakness, BP changes, elimination problems, & sweating -D/t infectious nature of GBS, often recover quickly but some may become paralyzed or experience resp. failure -Dx: electrodiagnosis to look for demyelination associated with Schwann cells or several motor nerves & cystological evidence of lymphocyte infiltration into peripheral nerve region -Interventions: therapies that have immunomodulatory properties like plasma exchange & high-dose immunoglobulins; CSF may be filtered to remove pathogens; anti-viral agent interferon-B, emplasis is more on supportive and symptom relief; NSAIDs like COX-2 or cyclooxygenase-2 inhibitors are used for pain tx -Need careful resp. support, VS like HR and BP monitored closely, & vascular system kept patent

Clean Bowel

-Refers to one that doesn't contain impacted feces; achieving one is part of an interventional bowel program; generally achieved by some soft of manual procedure or laxative use or rectal enema; laxatives: substances that escalate small bowel & colon motility, usually administered orally, are effective within 8-12 hours, & include MOM, mag citrate, oil suspensions, or bisacodyl -Enema: used less often to establish clean bowel because that can eventually compromise elasticity of colon walls; suppositories are sometimes inserted rectally to instigate reflex emptying of bowel as adjuncts, most act within an hour of insertion & include glycerin, sodium bicarbonate, potassium bitartrate, & bisacodyl-based products -Small volume enemas consist of stool softeners and/or bulk formers & are used to help achieve clean bowel by initiating evacuation; main manual procedure is digital stimulation using gloved, lubricated hand against inside of anal sphincter to relax it

Amyotrophic lateral sclerosis (ALS)

-Relatively rare, progressive & usually fatal neurological disorder characterized by muscle weakness & atrophy; appears to be related to presence of 1 of 2 genetic haplotypes for vascular endothelial growth factor (VEGF) that depress its levels; involvement is usually asymmetric with upper body sites more affected; motor rather then sensory are affected -Symptoms: difficulty speaking or swallowing & resp. function abnormalities -Dx: nerve conduction & electodiagnostic studies, brain MRI, or other scans for exculsion, lab tests to test for venereal disease, transcranial magnetic stimulation, or superoxide dismutase levels (more controversial) -Interventions: muscle relaxants-dantrolene, baclofen, and tizanidine for spasticity; neuropathic pain-Neurontin and other pain-morphine, Fentanyl; excess secretions in throat & resp. tract minimized through scopolamine or injectable Robinul

Motor & Sensory Paralytic Bladders

-Result from respective damage of efferent or afferent portions of micturition reflex arc, usually at S2-S4 level -Motor: feelings of fullness & emptiness but motor functions & tone are diminished: thus, usually have difficult or incomplete urination; etiologies-herniated disc, trauma to pelvis, poliomyelitis -Sensory: can't sense voiding needs, can generally initiate voiding; tend to have high-volume but infrequent voiding patterns; results from childbirth w/DM, PVD, pelvic trauma

Autonomic Dysreflexia

-Return of certain reflexes after spinal shock subsides; phenomenon occurs most often with SCIs above T6; chemicals such as norepinephrine & dopamine are released that cause vasoconstriction & rapid rise in both BP components -Symptoms above level of injury: sweating, skin flushing, intense headaches, fuzzy vision, nasal congestion, & cardiac abnormalities -Potential causes: UTIs, bladder or kidney stones, fecal impaction, bladder/bowel distention; procedures: cystoscopy, vaginitis, L/D -Underlying must be quickly identified & managed Management -BP should be taken & subsequently monitored along w/pulse: if BP is high; seat pt, remove restrictive clothing & equipment, and ID cause ASAP -Urinary problems generally predominate; if pt does not have indwelling urinary catheter, place one w/ 2% lidocaine jelly; existing indwelling catheters should be checked for obstruction; once catheter is draining, BP should normalize & other symptoms should subside -Fecal impaction also likely; if SBP >/=150, give antihypertensive drugs & monitor to make sure hypotension does not result; once SBP is <150mmHg, fecal impaction is checked & removed if found, topical anesthetic (lidocaine) is used in rectum -If episode is still not resolved, patient should be admitted & other causes pursued; document all!

Spinal Cord Injuries (SCIs) card #1

-SCI can be result of direct or indirect damage to structure; in US, nearly 80% of SCIs occur in males; most common types of direct trauma are violent forward flexion of neck or forceful backward hyperextension of head during MVA, twisting (flexion-rotation) of head, compression of vertebral bodies during fall, & direct penetration of cord during incidents such as stabbing or gunshot wounds -Indirect trauma can occur through lack of blood to cord, inflammatory processes, cell destruction & electrolyte imbalances, programmed cell death (apoptosis), & tumors pressing on spinal cord -Vast majority of SCI victims develop some degree of either paraplegia or tetraplegia, w/ latter occurring w/ damage in higher vertebral areas (about C1-C8); many are vent dependent Patient Classification at Admittance -Rehab nurse should follow American Spinal Injury Association's (ASIA) Impairment Scale when classifying pt w/ SCI at time of admittance; essence of classes is identification of neurological level of impairment (NLI) & whether there are zones of partial preservation (ZPP) -SCIs don't affect facial sensation; therefore ratings are done relative to facial sensation; 28 areas or dermatomes on each side of body are checked by pinprick & light touch & graded as either 0 (incapable of distinguishing sharp from dull), 1 (differentiates sharp from dull but not like on face), or 2 (a normal response) -Impairment at top cervical (C2-C8) or first thoracic (T1) level usually indicates tetraplegia while lower thoracic (T2-T12), lumbar (L1-L5), or sacral (S1-S5) damage generally means only lower extremity paralysis; 10 importation flexor or extensor muscles are also tested on each side for strength on scale from 0-5

Clean Technique Intermittent Catheterization

-Safely performed using clean technique using new sterile catheters q 6 hours or less -If has not voided between catheterizations, volume limit is 40mLs; privacy must be protected during procedure; the caregiver performing catheterization washes hands, dons gloves, exposes urinary opening by lowering clothing; puts lube on catheter tip, exposes urinary opening by pulling back foreskin or spreading labia -Position urine collection device (if needed); insert catheter, drain urine into collection device or toilet; diminishing flow can be aided by manual pressure; remove catheter, wipe lube off, wash peri area; if male-replace foreskin; discard used supplies; wash hands

Goal Setting for Effective Rehabilitation

-Should be mutual process between pt & members of rehab team; if patient feels they have a role in establishing goals & making decisions r/t their rehab & that those goals are clear-cut, personally relevant, & achievable, studies have shown that ability to cope & work toward those goals is greatly enhanced -Goals developed should be designed to utilize strengths of both pt & family & promote pt's independence -Should also be planned w/consideration for effective coping, health maintenance, & accessibility to other resources embedded; strategies should be personal keeping in mind cultural preferences & developmental level of pt

Nursing history covering nourishment issues

-Should cover 4 areas --1st: methods for acquiring & preparing food, including things such as number of & transportation mode for grocery store trips, ability to prepare food, configuration of prep area, & manual dexterity, & adaptive devices used by patient; if employed, they should also be consulted about these questions --2nd: nutritional habits & patient preferences; include meds, allergies, fluids consumed, eating patterns, & dietary recommendations, including adherence --3rd: history should cite ability to place food in mouth independently in terms of adaptive devices needed, ability to open food containers, whether they have SOB during any point in process --4th: presence of any factors that would affect ability to chew or swallow-such as previous aspiration pneumonia, pain or trouble during deglutition, nasal regurgitation, chocking or couching, special food prep or technique needed in order to swallow

Desired Outcomes for Bowel Dysfunctions

-Should establish a regular BM pattern daily to q 3 days under control, at established times, & without use of measures to promote it -Eventually texture of stool should be normalized & episodes of incontinence diminished or eliminated; nurse responsible for establishing exercise schedule & diet plan w/enough fluid & fiber such that these goals are achieved without introducing other complications -Also outcomes specific to various types of neurogenic bowel; for uninhibited bowel, main goal is establishment of regular pattern; for reflex neurogenic bowel, measures that encourage reflex movement into rectal area are indicated; for autonomous neurogenic bowel, main objectives are predictably firm stools & relatively empty colon

Nursing Assessment for Cognitive Networks

-Should observe degree of arousal & ability to focus attention; short-term & long-term language & non-language memory need to be assessed; short-term memory can be evaluated by studying whether they are oriented or confused in some way & also by asking questions to see whether pt is able learn new information -Similarly, questions r/t long-term memory should be asked; clinician should look at aspects of pt's ability to form concepts such as facility to categorize, think clearly, & formulate abstract concepts; executive functions of vigilance, detection, & working memory should be evaluated -Person exhibiting vigilance will actively search environment; cognitive assessment of detection function encompasses things such as looking to see if pt is motivated, expresses emotion, & is aware of current pattern of communication; working memory is concerned w/ ability to sustain attention or concentrate over time

Alzheimer's Disease (AD)

-Slow & subtle destructive form of dementia; involves cognitive & intellectual deterioration d/t destruction of brain cells; another type of dementia (vascular dementia), can result from diminished blood flow to nerve cells in brain, & term mild cognitive impairment (MCI) used to describe transition to dementia; primary risk factor is aging; presence of AD in a close relative also increases probability of its development; while exact etiology of AD is undetermined, pathological alterations include development of neuritic plaques containing protein beta-amyloid, neurofibrillary tangles enclosing abnormal proteins, & a deficit of cholinergic neurons r/t memory & cognition -During initial stages (up to 3 years), typical presentation is primarily mild memory loss; in stage II AD (up to 10 years after onset), memory impairment is more pronouced-symptoms at this stage include spatial disorientation, restless, indifference, irritability, delusions, speech deficits, & self-care issues; stage III (11 years or more), grossly impaired cognitively, has rigid limbs, & is incontinent Management -Currently managed pharmacologically & through types of interventions; most of currently approved drugs for AD fall into category of cholinesterase inhibitors (galantamine, rivastigmine tartrate, & donepezil) all of which employ different mechanisms to stabilize neurotransmitter acetylcholine (which is diminished in AD) -Drug called memantine, works by depressing levels of another neurotransmitter, glutamate; glutamate can kill brain cells if present in excess; only about half of AD patients benefit from these drugs & other drugs are being investigated -Nonpharmacological interventions primarily address behavioral abnormalities associated w/ AD & include things as music therapy, movement therapy, & auditory or tactile stimulation techniques

Spinal Column & Spinal Cord

-Spinal column: basically vertical structure made up of 24 vertebral bones plus sacrum & coccyx bones at base; interspersed between vertebral bones are areas of cartilage & other fibers called vertebral discs; there is a foramen or natural opening in middle of vertebral bones called spinal cavity -Spinal cord: containing nervous tissue, CSF (acts as shock absorber), meninges or protective membranes, blood vessels & other tissues are all present in spinal cavity; consists of white matter, nervous tissue comprised of myelinated nerve fibers, & gray matter (mostly comprised of nerve cell bodies) -Information sent in both directions between brain & spinal cord through either descending (motor) or ascending (sensory) tracts

Caregiver Roles

-Tend to be either engaged, conflicted, or distanced; those who are actively engaged ascertain the needed care, anticipate needs, & deliver care skillfully & supportively; conflicted caregivers are less engaged & prepared, deliver care primarily only when necessary, & tend to encourage pt to participate in decisions; distanced caregivers make person being cared for primarily responsible for their own care & decisions -Often spouse is caregiver & can assume a variety of roles; those who are active participants are generally very supportive & positive; others take on a more regulative role w/ more authoritative & controlling manner of communication; spouses may also act in merely observational manner, in which they are empathetic but relatively acquiescent -Partners can also assume roles that are not particularly helpful to patient; may assume a dissociative role in which they are negative & openly reluctant to participate; partner may also assume an incapacitated position where despite an interest in helping patient, partner has their own issues

Deep Vein Thrombosis (DVT)

-Thrombus or blood clot formation in deep venous system of legs, resulting in thrombophlebitis (inflamed vein) or phlebothrombosis (no inflammation) -Blood clots form d/t stoppage of blood flow, hypercoagulability of blood d/t increased levels of coagulation factors for platelets (fibrinogen) and/or vessel wall injury -Thrombus begins at outer edges of blood vessel & organizes inward to fill & occlude vessel -Inflammation often occurs because inflammatory, white blood, & immune cells as well as fibroblasts are recruited to area -Circulation may be shunted to superficial veins -If iliofemoral or axillary veins are occluded, only limited collateral circulation can occur, causing increased venous pressure, blood vessel distension, edema, & fluid/electrolyte abnormalities Risk Factor Assessment -Increases with age (at least 41), hx of prior surgeries, obesity, acute MI, COPE, swollen legs, sepsis, in women-recent pregnancy, abortion, premature birth, or hormone use -Even more likely if at least 60, had arthoscopy or laparoscopy, in a cast, or has CVC; risk compounded if over 75, prior hx of DVT or PE, certain elevated serum markers (+prothrombin variants, elevated homocysteine, anticardiolipin antibiodies, +lupus anticoagulant -If has had recent hip, pelvic, or leg fracture, stroke, trauma, or spinal cord injury=at greater risk for DVT -Risk factors are additive, prophylaxis generally depends on cumulative risk level

UMN & LMN

-Upper motor neuron syndrome (UMN) is CNS damage resulting from disruption of any motor systems controlled at point of disturbance; functional deficits cam include loss of muscle tone (hypotonic muscle tone) & strength, partial ability to move, weakness, fatigue, & reduction in motor skills; in other instances, UMN can result in increased muscle tone (hypertonic muscle tone) & magnified reflex reactions or malfunctions such as spasticity -UMN syndromes can occur when damage occurs in brain areas of motor cortex, internal capsule or brain stem, & spinal cord; similar pathological conditions may result from different areas of damage --Examples: childhood cerebral palsies & MS -Lower motor neuron (LMN) usually occurs when peripheral nerves, junctions, & associated muscles are damaged, resulting in either paralysis or deficits in reflexes & voluntary movements --Examples: muscular dystrophies, polio, & bulbar palsies

Milieu Therapy

-Utilization of any resources, people, or events in pt's setting that can enhance psychosocial functioning, it is suggested intervention for those diagnosed w/ impaired social interaction, basically milieu therapy involves provision of an environment in the ward conducive to rehab; -Includes the following: a light-hearted & encouraging atmosphere among rehab nurses & patients, availability of resources & activities such as computers & places for family members to obtain food, & pleasant use of sounds (piped in music, nurse's tone of voice, etc.)

Disability evaluation tools

-WeeFIM (age 6 months to 16 years) -WeeFIM II (child up to age 3) -Both tools are provided by Uniform Data System for Medical Rehabilitation (UDSMR) -Take into account developmental age & are used mainly as outcomes measurements for institutions -Pediatric evaluation of disability inventory (PEDI) looks at functional skills r/t self-care, mobility, & social functioning in children between 6 months & 7 years of age; may used in children with abilities below chronological age-RN interviews parents about functional domains, also can assess environment

Spinal Shock & Affect on Bladder Function

-When spinal injury occurs, temporarily develops spinal shock or loss of all reflex capabilities below level of spinal lesion -Initially has no control over urinary voiding & can't tell when bladder is full; as result, bladder becomes over distended; these symptoms resemble autonomous neurogenic bladder, usually associated w/ injury to sacral reflex arc -Nurse's main role is handling urinary retention -Once recovered, true area of CNS injury & consequent type of neurogenic bladder can be pinpointed more accurately

Pediatric rehab card #1

2 primary goals of interdisciplinary team in ped rehab -Provision of care -Self maintenance Practice standards -Responsibilities of ped rehab nurses (1992) --Bear high professional standards --To be PCP w/ theoretical, content, & systemic approaches to care --To act as coordinators & team members --To be research participants --To be leaders --To be patient & family advocates --To pursue professional development --To be health educators Developmental profile for infancy -Period from birth to age 1, neonate is up to age 1 month -Learn to trust, go from stages from sitting to crawling to walking; explore emotions through crying & motor activities like kicking & sucking thumb or pacifier -Disabled infants have limited environment exploring & do not have proper sensory stimulation; need to good have sensory stimulation, as much freedom as possible, soothing & nurturing -Parents of disabled neonate often feel guilty --Encourage to bond with child --Give info about disability Developmental profile for toddlerhood -Defined as period from age 1-4 -Learns skills such as walking, climbing, drinking from cup, communication through language & using toilet -Child also develops independence & separates from parents & develops ability to talk -Very egocentric, tend to cope by insisting on attention, throwing temper tantrums, crying or other behavior problems -If disabled, may have restricted mobility and/or elimination difficulties & other problems that cause them to be more dependent, interfering with ability to separate from parents -Interventions: Activities that promote independence & mobility, reduce anxiety, set boundaries, & teach w/ methods specific to needs (ASL)

Drugs used to treat cardiovascular diseases

ACE inhibitors: Lotension, Accupril Beta blockers: Inderal, Sectral Calcium channel blockers: Cardizem, Norvasc Diuretics -Thiazide: HCTZ -Loop: Lasix -Potassium sparing: Aldactone Angiotensin receptor blockers (ARBs): Benicar

Ineffective breathing pattern

Adequate O2 needed for cellular requirements can't be maintained Main example of obstructive/restrictive defects is cystic fibrosis -Restrictive: neuromuscular diseases, SCI, bony deformities in chest wall, pulmonary fibrosis -Obstructive: chronic bronchitis, emphysema, asthma, BPD, cystic fibrosis Breathing training: goal is optimization of ventilation & improved airway flow; pursed lip or diaphragmatic breathing Pulmonary rehab, ventilator support devices (rocking beds, pneumobelts), energy conservation methods

Urinary Incontinence Treatment card #2

Advanced Pelvic Muscle Rehab Techniques -Most are used in conjunction w/Kegel exercises -Vaginal weight training: vaginal cone is inserted & woman attempts to hold on to it as long as possible; once a particular cone is retained for 15 minutes, a heavier one is used; enhances proprioceptive (theory) -Biofeedback: uses monitoring devices to measure physiological responses; electrodes placed on skin or intra-vaginal or -rectal sensors to record responses that visualized on screen; educate pt to perform contractions correctly (goal) -Stimulation of pelvic floor: using sensors in order to instigate sphincter contractions & diminished reflex actions in detrusor Drugs -1st set is directed toward tx of urethral sphincter deficits & these include alpha-adrenergic agonists such as phenylpropanolamine & estrogen replacements in postmenopausal women (also in conjunction w/ progestin) -2nd set use anticholinergic & antispasmodic drugs such as tricyclic antidepressants & calcium-channel blockers (for detrusor overactivity); utility stems from ability to relax bladder & allow for greater filling Surgery -Depends on underlying cause (hypermobility or sphincter issues), either suspension or a sling/artificial sphincter -Urge incontinence d/t instability of detrusor can be managed by using plastic sx to enlarge bladder -Overflow issues can be treated by surgical removal of obstruction or intermittent catheterization; transurethral sphincterotomy can be used to manage neurogenic bladder dysfunction, detrusor-sphincter dyssynergia -Augmentation enterocystoplasty: uses small intestine, bowel, or other tissue to create continent diversions; newer & somewhat experimental is insertion of spinal nerve stimulators at S2-S3 level

Sexual Dysfunction card #2

Alleviating Dysfunction d/t Motor or Sensory Function Problems -Hypertonicity is major motor problem in patients w/ CNS impairments as r/t sexual function; if hemiplegic, person can lie on affected side; if they are paraplegic or has apraxia or ataxia, partner must initiate and/or direct movement to achieve sexual response; important to recognize autonomic dysreflexia in SCI patients & stop activity if it occurs -A wide range of sensory changes that may apply to sexual activity can occur in patients w/ SCI, ranging from loss of genital sensation to heightened responses resembling orgasm in other areas (pseudo orgasm); effective techniques addressing sensory deficits include visual stimulation (men especially), touching other areas, & other methods of increasing desire or release such as mood music or verbal encouragement Managing Other Associated Issues -Pain control is crucial for sexual functioning in several populations, notably those who have rheumatic disease or have had recent joint replacement surgery & postmenopausal women -Those w/ rheumatic disease generally need to control joint pain & stiffness before they can enjoy sex; this can be achieved many ways including relaxation techniques, ROM exercises, moist heat application, pain meds including corticosteroid injections, & massage -Postmenopausal women as well as others w/ nerve or blood vessel issues may suffer vaginal dryness & discomfort, which can be addressed w/ lubricants or estrogen creams; incontinence during sex d/t autonomic reflexes is common in patients w/ neurological issues; prep for this possibility includes prior emptying, scheduling activity relative to bowel programs, & use of protective bed coverings -Medication dosage changes or alterations can augment sexual function

Pediatric respiration

Anatomical differences -Relatively small airways, slower development of distal respiratory passages, immature cartilage & intercostal muscle support until ~age 5, larynx that is further forward than adults, proportionately larger tongue, cartilaginous ribs Physiological differences -Immature CNS breathing control (esp. infants), fewer alveoli to facilitate gas exchange, increased O2 consumption

Eye & Vision card #1

Anatomy -3 layers to eye --Outer later: protective fibrous tunic comprised of membranous cornea in front covering iris & pupil & sclera or tough outer covering of eyeball --Central layer: called vascular tunic; comprised of following: iris (colored muscular part surrounding pupil), ciliary body (muscular & controls lens shape), & choroid (contains blood vessels & pigmented cells & removes waste from front of retina) --Inside layer: called nervous tunic because contains retina, a light-sensitive membrane in rear of eye that receives images from lens & communicates them to brain via optic nerve; retina composed of rods (sensitive to dim light & account for peripheral vision) & cones (which are sensitive to colors & are responsible for daylight vision) -Other eye structures include eyelids, the membranous conjunctiva lining lids, the aqueous lens which changes shape to accommodate near vs. far vision, cavities that primarily control pressure in eye called the aqueous (anterior) & vitreous humors, & a system of glands & ducts controlling tears called the lacteal apparatus Neuronal Pathways -Light rays come into eye through pupil (controlled by darker adjoining iris) & an image is recorded on retina in posterior of eye; light passing through center of visual field crisscrosses at retina; there are also other visual fields such as those associated w/ peripheral vision -At retina, electrical impulses are generated-these travel along optic nerves through optic chiasma or crossing point into optic tracts & then into lateral geniculate nuclei on opposite side-these nuclei are located in geniculate body of thalamus, which is further located by optic radiations terminating in visual cortex of occipital lobe where impulses are deciphered

Drugs used to control bladder elimination

Anticholinergic: Ditropan, Detrol Tricyclic antidepressants: Tofranil, Sinequan Conjugated estrogen-Premarin (vaginal or topical patch) Alpha-adrenergic agonist-(Sudafed) BPH meds: Flomax, Proscar, saw palmetto Urecholine aids in bladder tone

Drugs that influence cardiovascular function

Antiplatelet: Aspirin, Plavix Anticoagulant: Coumadin Aggrenox-CVA prevention Cholesterol-lowering agents: Lipitor, Zocor, Colestid, niacin

FIM (Functional Independence Measure)

Assesses ability of patient to perform ADLs; 18 parameters rated 1 (complete dependence) -7 (safe independence); complete independence is 126 points, absolute dependence is 18 points or less for all parameters

Burns card #2

Assessment & Classification of injuries -Minor, moderate, or major based on total body surface area (TBSA) involved, thickness, patient age, presence of other injuries or preexisting conditions, & burn site -TBSA: often determined using "rule of nines"-partitions areas of body into multiples of 9%; anterior & posterior sides of head, torso, each arm, & each leg are assigned 4.5%, 18%,4.5%, & 9% respectively -Minor: <15% TBSA (adults), <10% (children/elderly) w/ <2% TBSA full-thickness injury & no preexisting conditions -Moderate: 15-25% TBSA (10-20% in children/older adults) & u to 10% TBSA full thickness but no concomitant injuries or previous conditions -Major: >25% partial thickness TBSA (>20% in children/older adults), 10% full thickness TBSA, critical burn sites such as face or hands, or patients with preexisting disease like CHF -Electrical burns & those w/accompanying inhalation are considered major -Initial assessment: should include nature of injury (including explosion if present & thermal agent) & duration of contact Interventions for impaired skin integrity -During acute phase; necessary debridement, scab removal, & grafting if necessary -During rehab phase; nurse responsible for wound & maintaining skin integrity --Usually involves use of topical agents such as 1% silver sulfadiazine or mafenide acetate to avoid infection of fragile skin --Skin dryness: addressed w/topical emollients made of both water & lipid because both will absorb & slow down evaporation --Agents to control pruritus or itchiness: systemic (antihistamines) & topical (antipruritic lotions incorporating menthol, camphor, anesthetics) -Instruct pt to stay out of sun or cover up when outside for al least 6 months to avoid sunburn & permanent hyperpigmentation of burned area -Related issue is possible imbalance of nutritional requirements d/t loss of bodily fluids

Coping with Health Issues card #3

Assessment of Coping Ability -Should include historical, subjective, & objective data as well as evaluation of certain physical s/s; nurse should ask historical questions about person's previous lifestyle & current circumstances, including things such as health beliefs, developmental stage, & therapies utilized (including perceived effectiveness) -Can be further evaluated by asking about lifestyle & relationship changes, patient concerns & difficulties, amount of control pt perceives having over situation, pt's ability to adhere to health care plan, & pt's resources & strengths -Nurse should check for physical symptoms of stress such as: tachycardia, dyspnea, stomach problems, elimination issues, nervous twitching, pain, communication problems, or skin eruptions -Objective data includes weight, vital signs, BP, system reviews, inspection for injuries, documentation of all therapeutic items used, ability to describe precipitating event & observation of emotional state Assessment of Family & Caregiver Coping -A person w/ a disability or chronic illness is generally part of a family system that must deal on a long-term basis w/ patient's affliction; these family members can become overwrought, especially if they assume role of primary caregiver; especially true after patient leaves hospital or rehab facility & reenters community -Signs of collapse in caregiver(s): fatigue, exhaustion, rage, extreme anxiety, sickness or accidents, sleeping problems, depression or thoughts of suicide, substance abuse, eating disorder, & lack of attention to their own care; caregiver may voice vexation about their role & feelings that their choices are limited and/or that their resources are exhausted or available

Brain Injuries card #1

Associated Cognitive Defects -Cognition is integration & processing of information w/ awareness & judgment; brain injuries usually cognitive defects; RAS damage can affect alertness, attention span, & arousal; can induce coma; most other cognitive defects are associated w/ brain injuries to parts of cerebrum -Various types of memory deficits are linked to injuries in portions of frontal lobe or hippocampus & other types of limbic system also associated w/ cerebrum; hippocampus injuries generally affect immediate or short-term functions & limbic system injuries can also suppress motivation -Damage to portions of other lobes of cerebrum (parietal, temporal, & occipital) tends to affect long-term memory; L or R hemisphere injuries can cause loss of mathematical & language skills or loss of recognition & artistic skills respectively; injuries to amygdala in cerebrum, which modulates emotional responses to memories, can precipitate wild mood swings Associated behaviors (can occur w/ brain damage) -Disorientation/confusion-bewilderment & loss of direction, position, or time resulting from altered attention span & memory -Depression-state of unhappiness & hopelessness manifesting as withdrawal, weeping, apprehension, & petulance -Impaired judgment-incapacity to assess consequences of actions & respond appropriately -Impaired problem solving-incapacity to describe & analyze problem, come up w/ strategy to deal w/ problem, & analyze results -Impulsivity-inclination to act in response to sudden urges or desires w/o considering consequences -Disinhibition-loss of inhibition, incapacity to verbalize & behave within societal & cultural standards -Agitation-highly unrestrained behavior characterized by nervous anxiety, irritability, & lack of attention span -Apathy-lack of motivation & empty, emotional emptiness -Lack of initiation-failure to independently instigate & follow through on actions -Lack of insight-lack of self-awareness & inability to see situation clearly often leading to denial -Emotional lability-quickly changeable & inexplicable shows of emotion (crying/laughing) -Perseveration-reflexive repetitive responses in appropriate situations, responses can be either spoken phrases or repeated actions -Confabulation-fictitious creation of details about past events to compensate for memory loss & to alleviate anxiety, often seen in patients w/ dementia -Nurse should not merely tolerate any of behaviors but should instead strive to provide an environment that will enable patient to gain control over these behaviors

Sexuality in Disabled Patients card #1

Birth Control -Options w/ lowest failure rates (3% or less) are hormonal-based, although they may be contraindicated in patients who have additional CV or other problems; those that suppress ovulation include oral contraceptives & Norplant (implantable levonorgestrel); depo-provera or medroxyprogesterone acetate controls menstrual cycle -Barrier methods include intrauterine devices to prevent implantation, diaphragms which provide a physical sperm barrier, sponges over cervix, & male condoms; all of these may be used in conjunction w/ spermicidal forms or creams, & lowest failure rates have been linked to condoms & diaphragms -Coitus interruptus (withdrawal prior to ejaculation) & use of natural methods such as rhythm or basal body temperature generally have much higher failure rates -Most effective means of preventing pregnancies is permanent sterilization through make vasectomy or female fallopian tube ligation Physical Adjustments for Sexual Intercourse -Most disabled patients can modify major sexual positions of face-to-face (w/one or other on top), side-lying, or rear entry to be comfortable; patients who have been relatively immobile do need to be careful to avoid fractures-it is recommended that they use their brace during sex -Positions that put minimal stress on joints should be used by individuals with rheumatic diseases; supportive pillows & side-lying positions are generally recommended for patients w/ arthritic hip joint issues -It is recommended that those w/spasticity due to SCIs or other neurological problems assume the bottom position d/t lack of control; this position is also suggested for those at risk for MI, & for those people, HR should be monitored for about 15 minutes after intercourse

Eye & Vision card #3

Blindness -Considered legally blind when has corrected vision of at least 20/200 (meaning they can only see 1/10 amount of normal person) in stronger eye; functional blindness, is used to describe people who can't see light & are totally blind; individual considered to have low vision if Snellen reading is minimum of 20/40 -Most prevalent cause of blindness & low vision in Caucasians is macular degeneration, progressive deterioration of macula lutea resulting in central vision deficit; most common causes of blindness & poor vision in African Americans are cataracts & glaucoma, diabetic retinopathy can also precipitate visual shortfalls in certain fields Rehab for Low Vision -Rehab approaches for people w/ low vision center around use of large type or instruments to magnify images or change light received in some way; many large type books & other documents are currently available & a person can use a movable reading triangle to focus on small passages of reading material -Depending on distance of object(s) being observed, instruments for magnification include microscopes for close work, magnifying glasses for reading & writing, & binoculars or field glasses (both of which are really telescopes) for distant observations; major drawback to all of these is that they require hand use & coordination; eyeglasses can be modified to reduce glare through use of light filters over glasses or incorporation of tinted lenses; glass prisms that redirect images in retina can be utilized as adjuncts to promote vision, require hands Assistance of Visually Impaired with Daily Life -Manner of speaking is important, should speak in natural tone of voice w/ very clear instructions that are separated into small discrete steps; can visually impaired patient cope w/ daily life by organizing pt's personal space, maintaining layout of personal items & furniture & using aids such as symbols sen on clothing to help them ID objects -There are techniques that can be utilized in regards to meals, such as describing location of foods on plates in terms of clock positions or holding glasses at certain level to avoid exposure to overly hot or cold liquids; when providing walking assistance, helper should be slightly ahead of visually impaired patient while pt clasps helper's arm above above w/ thumb on outside; if both people keep arms near their bodies, pt can feel & respond to movements

Ineffective airway clearance

Can't discharge secretions or airway obstructions, often d/t neuromuscular diseases Treatment: beta2-agonists, anti-cholinergics, methylxanthines Cough techniques: controlled, huff, pump, or quad cough Chest physiotherapy: percussion (cupped hand), vibration (flat hand); postural drainage helps drain affected lobes & airway segments Other interventions: O2 humidity, suctioning, deep breathing Trach interventions: humidity via trach collar, clean with H2O2 and NS q 8 hrs, suction at 60-80 mmHg

Assistive Devices for Ambulation card #2

Canes & Walkers -Both should be customized, canes are intended for use by patients who have weakness or paralysis on one side of body; canes can be single straight canes or 3-4 footed & should be used on unaffected side; length should be equivalent to distance between individual's greater trochanter & floor -Walkers are designed for patients w/ global weakness; types include pickup (have adequate balance & UE strength to move), reciprocal (moves one side at time for patients w/o these abilities), & rolling walkers Other Devices -Orthotic: any type of brace/other device that can assist mobility; range from corrective shoes & inserts to various types of braces; leg braces are often used by individuals w/ inability to move to one side; braces may be knee-ankle-foot (long) orthoses or a shorter leg brace; brace may be connected to shoe to discourage ankle pronation -Prosthetic devices: customized apparatuses to replace body parts after surgery; patient is fitted for permanent prosthesis after shrinkage of remaining portions of affected limb has concluded; other, more controversial, approaches to facilitation of ambulation such as electrical stimulation

Pediatric rehab card #3

Care setting options for special needs -Services have shifted from inpatient to outpatient or community-based programs (home health care services) -Main role is educator, since in home limited number of hours-need to teach family members about child's care -State programs & federal Medicaid programs=major sources for service reimbursement -Other care settings: outpatient clinics, therapy units, school setting services; family needs to be included in rehab process -Respite care or temporary residential care: gives parents or regular caregivers time off to relax & renew themselves --Authorized by feds for state funding Individual with Disabilities Education Improvement Act (IDEA) 2004 by US dept of education -Access from 3-21 to free & suitable education -ID children w/ special ed needs -Individualized ed plans (IEPs) for each child -Procedures for parents to be involved in process -Evaluation protocols -Confidentiality -Transition services into preschool & out into adulthood -Processes to correctly classify minority children -Grants for early intervention services for children under 3

Pressure Ulcers card #2

Classification -PUs placed into one of 4 groups defined primarily in terms of depth of skin loss -Stage I: areas of pigmentation change (red, blue, or purple), possibly accompanied by temperature differences, tissue texture, or sensation, but skin is intact -Stage II: visible skin loss appearing as a blister or crater extending into epidermis & perhaps dermis as well -Stage III: ulcer is deeper & has penetrated into SQ layer but not into fascia or supporting tissue; in areas like nose or ear where there is no SQ tissue, a stage III ulcer is not is as deep -Stage IV: deep enough to cause damage to cause tissue necrosis or death & damage muscles, joints, tendons, & bones; at this stage, ulcer may tunnel into various sinuses or undermine wound bed; undermining is extension parallel to surface of skin while tunneling or tacking is expansion in any direction -Deep tissue injury: purplish area that is either intact or has a blood-containing blister along w/ changes described in stage I -Unstageable ulcer: staging can only be done after eschar or dry scab has sloughed off or area has been debrided Documentation in Conjunction w/ Staging -Should be documented in terms of source, type, & anatomical location; usually measured in terms of length, width, & depth as well as length & direction of undermining and/or tracking; wound is often traced or photographed -Describe wound exudate, including color & amount (which may indicate infection); look at edges of wound (if rolled-may suggest chronic condition); surrounding should be assessed for presence of redness, swelling, or warmth (indicative of possible infection) -Tools for evaluation of wound healing that use various similar parameters measured sequentially; Pressure Sore Status Tool (PSST) & Pressure Ulcer Scale for Healing (PUSH)-PUSH rates surface area of wound, amount of exudate, & predominant tissue appearance; then multiples each of factors by weight factor & combines them to generate total score; can also be used to assess healing

Bowel Dysfunction

Classification Tests -Neurogenic bowel dysfunction can cause altered bowel elimination or bladder incontinence; 3 common tests to classify impairment type -1st: tests perception of defecation urge by use of pinprick or soft touch to perianal region -2nd: bulbocavernosus reflex evaluated by grabbing either penis or clitoris observing whether external anal sphincter contracts, contraction of bulbocavernosus & ischiocavernosus muscles can be felt as well; individual w/ upper neuron injury should + reflex while someone w/ lower neuron or areflexic damage should be unresponsive; reflex generally absent during spinal shock -3rd: skin near external anal sphincter can also be pricked to see if it contracts, known as anal "wink" reflex Neurogenic Bowel Dysfunction -Falls into 5 categories similar to those for urinary dysfunction: uninhibited, reflex, & autonomous neurogenic bowels plus motor & sensory paralytic bowels -Incontinence rarely occurs w/ latter 2 w/ damage in S2-S4 region; person w/ motor paralytic bowel has saddle sensation but absent bulbocavernosus & anal reflexes while the opposite is generally true in sensory region; uninhibited neurogenic bowel results from neural lesions in cortical & subcortical regions above C1; all sensations & reflexes normally associated w/ defecation are intact but brain can't decipher signals; voluntary control or anal sphincter is diminished & involuntary elimination can occur -Spinal cord lesions can result in either reflex or autonomous neurogenic bowel depending on level affected, above or at T12 to L1 or below T12 to L1 respectively; in both versions, pt can't control defecation or anal sphincter, but sacral involvement in autonomous bowel means they also have no spinal reflex arc & are incontinent between mass bouts of elimination

Arthritic disorders

Classified as inflammatory, degenerative, or metabolic Rheumatoid arthritis (RA) and juvenile RA-systemic inflammatory, also lupus, lyme disease (tick bacteria Borrelia burgdorferi), polymyositis Spondyloarthropathies: chronic inflammatory arthritis Gout (metabolic): uric acid salts deposit in joints--seen in males over 30 who are obese, alcoholic, heavy red meat eaters, hypertensive, have renal problems, or taking diuretics Tx: Promoting joint mobilization & moderate exercise, steroids, NSAIDs, methotrexate, Remicade

Respiratory tract structures

Conducting airways -Nose, pharynx, larynx, trachea, branches of bronchus, terminal bronchioles Respiratory units -Respiratory bronchioles, alveolar ducts, alveoli

Dysphagia card #3

Consistency, Size, & Temp of Food & Liquids -Thicker liquids pass through oral cavity & pharynx more slowly then thinner liquids; region of swallowing deficit dictates preferred liquid consistency -Thicker liquids recommended w/ those clearing pharynx or with cricopharyngeal sphincter problems -Bolus size of food or liquid is also important -Those susceptible to aspiration should be given smaller volumes while others may need larger boluses in order to initiate transit in oral phase or augment elevation & closure of larynx & opening of junction into esophagus -Some have increased sensory stimulation w/ cold, hot, or sour foods Postural Changes to improve Deglutition -Head down/chin tuck position is suggested most often as it allows the epiglottis to cover more of airway to prevent aspiration & also lowers pressure @ cricopharyngeal muscle -Holding head back (w/ or without turning) allows food to travel more quickly through oral cavity; these are good positions for patients w/ tongue use problems -For those w/ one-sided impairments, head is turned toward affected side in order to close pharynx on that side & permit food to move down the opposite portion; also relaxes cricopharyngeal muscle -If head is tilted toward more functional side instead, food proceeds down that side d/t gravity; turning head & keeping chin down protects larynx by directing food path -Gravity can be eliminated as a factor by having patient lie on their side with head propped up, also used for those w/ deficient peristaltic movement or laryngeal elevation; tumblers w/ cutouts, scoop dishes, & other special utensils can be used to maintain postures Swallowing Techniques to Improve Deglutition -With late pharyngeal swallow or impaired closure of vocal cords, supraglottic swallow is suggested (enhances airway protection & epiglottis closure); with or without food in mouth, pt inhales, holds breath, then swallows-then coughs/clears throat before next inhalation -Mendelson maneuver: insufficient laryngeal elevation of opening of cricopharyngeal sphincter; pt places hand on larynx & swallows to locate larynx position; then places food in mouth & swallows while holding larynx in highest position during swallow -Both of these exercises are repeated several times per session w/ 3-4 sessions/day -People who can't move base of tongue well are taught effortful swallows to enhance tongue base Rehab Team Members -Doctor: ultimately accountable for patient's management, refers pt to rehab team members, & prescribes dietary changes -Nurse: does patient hx, physical exam, self-feeding & swallowing studies, monitors essential parameters such as caloric intake, weight, hydration, & nourishment; also primary link between all team members & patient/family -Other team members: physical therapist (responsible for devising exercises to promote eating muscle tone); occupational therapist (educates on use of adaptive devices or exercises to improve hand movement); speech pathologist (does bedside swallow test, suggests compensatory postures & swallowing techniques to use, addresses speech problems): dietitian (does diet plan & monitors nutritional status)

Abnormal breath sounds upon auscultation

Crackles/Rales: Intermittent bubbling or crackling r/t pulmonary edema, lung collapse, pneumonia, or interstitial disease Wheezing/Rhonchi: Rattling or whistling sounds r/t blocked airways from spasms, secretions, foreign bodies Pleural friction rub: discordant or vibrating sound caused by pleura inflammation, pulmonary infarction, infection, or cancerous growths Stridor: upper airway obstruction

Renal system & disease card #2

Creatinine clearance & BP -Creatinine is derivative of amino acid creatine -Creatinine clearance or glomerulus filtration rate (GFR) shows rate of creatinine & is importance because is indicative of kidney function -Higher rates show proper kidney function -Usually estimated by Cockcroft & Gault formula --(140-age in years) x weight in kg/(72 x serum creatinine) -Certain drugs, systemic infections, chronic hypotension, & surgical or radiographic procedures can affect renal function temporarily -BP also influential since kidney can only regulate itself within arterial BP of 80-180 mmHg; if pt is hypotensive for sustained period, autoregulation terminates & kidney damage can occur Assessment of renal disease patients -Nephrology RN or NP take comprehensive history & ROS including risk factors for kidney disease -Physical exam should be broad since many systems can be affected by CKD --Neurological: dizziness, slow thought processes, diminished sensation possible w/ uremia, anemia, or peripheral neuropathy --Cardiac: BP abnormalities, arrhythmias d/t fluid overload, CHF, electrolyte imbalance --Respiratory: Cough, congestion, reduced oxygenation, low breath sounds, or cyanosis --Skin: dry, ulcerated, red, itchy, or bruised d/t disorders like uremic dehydration, hematomas, or clots at vascular access sites, of infections --GI: diarrhea, constipation, occult blood in stool; common causes are uremia & SEs of DM or meds --Reproductive & MS systems may also be affected

Dermatomes

Cutaneous areas innervated by spinal nerves -31 pairs of spinal nerves, most receive or control sensations from dermatomes -C2 to C8 relate to front and back of top parts of torso, arms, and digits -12 thoracic nerves control muscles & receive sensations in torso or arms -L1 to L5 control lower torso, legs, & feet -One coccygeal spinal nerve Impairment of spinal nerves results in reduced sensations in the corresponding dermatome

ADL Issues

Daily Personal Care Activities -Generally have difficulty washing hair; if can sit, can use shower seat for this; if can't, a pan can be used to rinse water lying down; nail care difficult w/ balance & ROM issues; since many are elderly or diabetic, nail care is crucial, necessitating intervention; patients can wear magnifying glass around neck for inspection purposes -Grooming actions, such as shaving for men, application of makeup for women, & deodorant use, may need to be need to be performed using creative measures; often pt's are renowned for neglect of oral hygiene-nurse can assist them w/ creative modifications in dental aid use & scheduling dental services -Disabled women of menstrual age may lack sensation, strength, or functional mobility to change pads or tampons; task may be made easier by manipulations such as sitting on raised toilet seat or forward in w/c, bracing against back of w/ , using mirror, or holding onto grab bar or locked w/c Dressing Issues -Those w/ limited ROM need to develop routines that enable them to dress themselves; if can't stand, use technique called bridging in which they flex their unaffected knee & push down on bed to raise hips; they then use good hand & arm to pull on pants -If can stand & balance, can start by sitting & using unaffected hand to elevate & cross affected leg over other one; they can then begin to draw pants over affected limb, uncross legs, insert good leg into other side of parts, then pull up pants & zip paints w/ unaffected hand -For putting on a bra, put on bra backwards while sitting & then switch to front; using unaffected hand, women placed affected arm into bra strep 1st & then fits in other arm & adjusts bra w/ her good hand; alternatives-hook-type w/ Velcro closures or stretch bras that can be pulled down from overhead or up after stepping into them -Those w/neurological syndromes who are confined to w/c can put on pants or underwear while seated; should lock w/c & then move to front of it while bracing against back of seat; then pulls each leg of pants up to knee in sequence while flexing leg & collects as much material as possible; briefly raises up buttocks, thighs, & eventually pants & afterwards sits further back in seat; while holding waist of pants, repeats pattern of sliding into pants & lifting as before until pants in correct position; in order to take off pants, pt sits forward, unfastens waistband, & pushes up to allow pants to slide down

Pediatric rehab card #2

Developmental profile for early childhood -Period from 4-6 years of age -Time when socialization skills & concepts of right/wrong are learned -Healthy traits: discover wonders of environment, develop independent skills r/t ADLs, has gender identity, mastered thought processes (questioning, fantasizing, fear) -May interact through routine activities, play, & aggressive actions or words -Disabled: limitations of mobility, communication, choice, & energy may lead to disrupted body image & routine & overprotection on part of family; give realistic choices & opportunities to act independently -Useful strategies: establish routines, set limits, use play in treatment schedule Developmental profile for middle childhood -Refers to age 6-12 -Large part of child's environment shifts from home to school & increased social interaction & independence -Learns academic skills, develops logical thought pattern, learns motor skills (bike riding), forms same-sex friendships -Also begins to consider viewpoint of others -Disabled: often misses school, can't engage in social & recreation events with peers, tends to feel inferior & dependent; may become depressed or act out by withdrawing, using humor, being aggressive towards others or trying to conceal illness -Interventions: encouragement of regular school attendance & participation in sports or clubs -At home: include child in self-care & household responsibilities & offer friend making opportunities (sleepovers) Developmental profile for adolescence -Ages 12-18 -Characterized by rapid & marked changes in physiology (r/t puberty), reasoning abilities, & abstract thinking, new viewpoint of personal ID, & increased interest in opposite sex -Period where child considers career & personal goals, gets into parental conflicts, transitions into adulthood -Disabled: negative body image, may have delayed puberty, feels isolated from peers & socially & possibly vocationally limited; may find it hard to be as independent as peers, may cope by showing resentment or withdrawal, may try to conform or take risks -Important to allow to fail, be as independent as possible, give them privacy, & provide social opportunities -Should also be given sexual info just like peers

Sexual Dysfunction card #1

Diagnoses, Interventions, & Outcomes -5 possible diagnoses are sexual dysfunction, activity intolerance, disturbed body image or self-esteem, altered sexual role performance, & deficient knowledge r/t sexual health -Sexual dysfunction issues dictate interventions such as sexual counseling encompassing variety of areas, including anticipation, self-esteem, body image, & coping w/ desired endpoint being sexual functioning; typically signals need for educational counseling on topics such as safe sex, fertility, risk factors, communication, & sexual functioning -If patient can't tolerate activity level, interventions are directed toward increasing general exercise & strength training & management of pain & energy use -Low self-esteem or body image can be addresses through counseling, socialization & support systems, & teaching ways to avoid incontinence during sex -Altered sexual role performance implies social isolation, which can be tackled primarily through complex relationship building & socialization techniques Alternative Techniques -Those w/ sexual dysfunction or an altered sexual relationship can often achieve satisfaction using alternative techniques such as masturbation, manual or orogenital stimulation, or lubricants -ED can be overcome by techniques such as positioning soft penis into vagina w/ man on top or by use of external vacuum pumps to engorge penis or penile vibrators; recommended drug therapy is use of oral phosphodiesterase-5 (sildenafil citrate, vardenafil, & tadalafil) all of which have various effective time ranges -If these drugs don's work or are contraindicated, other options include alprostadil intraurethral suppositories or intracavernosal injections' papaverine & phentolamine can also be given intracavernosal-all of these allow smooth muscle to relax & allow engorgement; penile prostheses can also be surgically implanted

Rheumatoid Arthritis (RA)

Diagnoses, interventions, & desired outcomes -3 possible nursing diagnoses --Chronic pain r/t joint inflammation: interventions include given drugs as directed & analgesics PRN, providing heat application to increase joint blood flow using alternative therapies for pain relief, & documentation; goal: reduction of joint pain --Impaired physical mobility r/t fatigue, pain, & inflammation: interventions include reinforcing joint & muscle exercises as given by PT, getting pt to walk & do other exercises, underline importance of ambulatory aids, & focus on pt's strengths w/ objective of getting them to ambulate independently --Partial self-care deficit r/t fatigue, pain, stiffness, & joint deformity: interventions include assistive devices, pain interventions, teaching processes for encouraging independent ADLs Pharmacological management -Usually starts w/ analgesic use to control pain (ASA, APAP w or w/o codeine, propoxyphene, tramadol, NSAIDs like ibuprofen & indomethacin) -Corticosteriods (have anti-inflammatory properties), may be given the 1st several months -Disease modifying: immunosuppressive (methotrexate, azathioprine, cycloposphamide, & cyclosporine) & remittive (gold salts, sulfa drugs, peniciliamine, & antimalarials) -COX-2 inhibitors: celecoxib (Celebra), immunomodulators: tumor necrosis factor blocker etanercept (Enbrel), hylan G-F 20 (Synvisc) mimics synovial fluid

Skin card #3

Diagnosis & Management r/t Skin Integrity -Nurse can reduce risk for impaired skin integrity by educating patient, identifying risk factors, & engaging in practices that will lessen possibility of damage (pressure management, positioning, examining skin regularly, providing nutritional support, & intervening when foot care is needed) -If skin has been compromised, should work to gauge & care for ulcerations, incorporate infection control measures, apply ointments PRN, & position affected area for optimal recovery -Consult w/ WOC RN may be needed -Other nurse roles are education r/t skin care, nutrition management if needed, & exercises or tasks to increase mobility or decrease pain & further damage -Nutritional management: fluid & electrolyte interventions, nutritional therapy & monitoring, & special diets; if mobility is impaired, nurse is responsible for providing a safe environment for patient, managing pain, aiding them in self-care, & promoting exercises if possible Disruption to Skin Integrity -Skin can be compromised in a number of ways; one most common is development of pressure ulcers; presence of ulcers tends to increase care-related costs & pt's inability to cope, heal & perform ADLs --Early signs: erythema, edema, & hardening, all of which may be hard to observe in patients w/ darker skin tones -Other types of ulcers: venous, arterial, & neuropathic foot ulcers develop frequently in older patients --Diabetic patients often develop neuropathic foot ulcers; another source of altered skin integrity is non-healing surgical or other chronic wounds

Brain Injuries card #3

Diffuse Brain Injuries -Involve extensive & scattered damage within brain; primarily diffuse axonal injuries in which forces of injury (acceleration, deceleration, & shearing) cause widespread damage); damage can be transient impairment or scattered axonal disruption & loss; these patients are usually comatose initially followed by increasing arousal & then confusion, may have period of post- traumatic amnesia, & then overcome confusion -many neuronal defects can be associated; if considerable intracranial pressure or compromise of CV and/or respiratory tract, another diffuse type of injury called diffuse hypoxic-ischemic injury can occur; here lack of O2 to brain, particularly hippocampus, basal ganglia, or cerebellum, results in diffuse neuronal loss, phenomenon known as watershed infarction or stroke from lack of O2 perfusion, and/or memory problems Focal Brain Injuries -Those involving distinct localized damage, focal cortical contusions commonly occur in frontal or temporal lobes because of associated bony structures; associated hemorrhaging, swelling, & tissue disruptions (including lacerations or tearing of meninges layer) are prevalent as well -Frontal lobe contusions manifest as emotional or social problems in patient, whereas temporal lobe injuries show up as language or cognitive issues; another type of focal damage called focal hypoxic-ischemic injury is secondary brain blood vessel blockage or necrosis-this occurs d/t swelling, pressure, or herniation within brain -Herniation: abnormal projection of areas of brain d/t shifting of tissue following injury resulting in compression & blood vessel & nerve damage; amnesia, aphasias, disorientation or other problems can result; deep hemorrhages in basal ganglia area are rare examples of focal lesions usually manifesting as opposite side motor weakness

Speech Disorders

Dysphonia & Dysarthria -Dysphonia: diminished or total loss of capacity to vocalize as result of dysfunction of vocal cords or associated nerves; reduced voice sounds can result d/t nerve damage, laryngeal carcinoma or polyps, or muscle paralysis or spasms -Several types of dysarthria (difficulty articulating speech d/t lack of muscle control); both central & peripheral system motor problems can result in dysarthria; most prevalent type is flaccid dysarthria characterized by breathy & nasal sounds & caused by damage to motor centers in brainstem and/or cranial nerves VII, IX, X, & XII -There are hypokinetic & hyperkinetic forms of dysarthria characterized respectively by slow & muffled or rapid & irregular speech patterns; spastic dysarthria or bulbar palsy is d/t corticobulbar injury; person has weak or no speech movement & unclear articulation -Cerebellar damage can result in ataxic dysarthria, in which person has episodes of explosive speech followed by barely audible words; patients may have mixed dysarthrias as well Other Speech Disorders -Stuttering, repetitive sounds interspersed w/halting in an attempt at pronunciation, is common speech-related disorder (especially boys); several motor areas of R hemisphere of brain have been implicated during stuttering as well as cerebellum while certain parts of cortex are unfazed -Has been postulated that stuttering may be d/t high levels of dopamine & serotonin in language processing & vocal areas accompanied by L cerebral dominance; other disorders include vocal tics, repetitive speech, echoing, extremely high or low pitch or loudness, abnormal nasal quality, broken words, inability to express thoughts in direct manner

Communication Disorders card #3

Expected Treatment Outcomes -Caregiving process for individuals w/ communication deficits can be objectively documented; there are goals for both patient & family members -1st & foremost is participation of patient in any type of activity designed to enhance communication skills; pt should eventually be able to control & express their frustrations -Should be able to function relatively independently & communicate to others things they can't do alone; pt needs to see themselves in positive light, be receptive to social interaction, & develop best possible pattern of communication -Effectiveness of family support can be verified by how well family can explain aspects of pt's problem, such as cause, prognosis, facilitation modalities, safety requirements, methods for recovery, & necessity of pt independence

Brain Injuries card #4

Extracerebral Hematomas -Areas of bleeding external to actual brain occurring between layers of meninges; create pressure on cranial space; types include epidural & subdural hematomas -Epidural hematomas: occur on outside of dural layer of meninges, usually subsequent to skull bone fracture & cutting of middle meningeal artery -Subdural hematomas: hemorrhaging into area between dura & arachnoid layers; usually occur after tears to bridge veins, pial arteries, or brain lacerations, & can occur quickly or later; latter slowgrowing versions known as hygromas; if not addressed quickly, subdurals can result in inadequate O2 supply & hypoxic damage can result Glasgow Coma Scale (GCS) -GCS & Glasgow Outcome Scale (GOS) evaluate severity of functional loss after brain injury during acute period; scales also rate probable outcome; GCS widely used & routinely performed 6 hours after injury or resuscitation; 15 point scale which assess eye movement & motor & verbal responses --Eye opening (E) rated from none (1 point), responsive to pain (2), responsive to speech (3) to spontaneous (4) --Motor response (M) rated from 1-6 ranging from none (1), extension (2), flexion but abnormal (3), pulls away from pain (4), localizes pain (5), to obeys commands (6) --Verbal responses (V) are assigned 1-5 points-none (1), incomprehensible sounds (2), unsuitable words (3), confused conversation (4), & an oriented verbal reply (5) --Components combined for a possible score from 3-15 points; score less than or equal to 8 indicates severe injury or a comatose state; score of 9-12 points indicates moderate injury, score of 13-15 indicates mild injury -GOS: broad assessment 3 months post-injury w/ good, moderate, severe, & vegetative state categories

Skin card #2

Extrinsic Factors Affecting Skin Integrity -Major one: pressure or application of outside force; pressure applied constantly increases likelihood of tissue damage more than intermittent pressure; mechanisms of damage include dilation of underlying blood vessels d/t O2 deprivation, edema results d/t leakage from blood vessels, impedance of blood flow, & accretion of metabolic byproducts -Shear: shifting of internal tissues against fixed outer skin layers; often occurs in those who are spastic or who have poor posture or bed positioning -Friction: rubbing against bed or other support; skin tears are separations between epidermal & dermal layers; moisture resulting from sweating, lack of excretion control, or seepage from wounds compounds chance for skin injury -Radiation damage to epidermal layer is other predisposing factor Intrinsic Factors Affecting Skin Integrity -Those w/ neurological impairments & other chronic diseases are prone to alterations in skin integrity because they can't feel or respond to these changes; wound healing is impaired in those w/ certain chronic disease, especially if person is immunosuppressed or has vascular issues -Nutrition & vitamin levels have been linked to propensity toward ulcer development & inability to heal wounds; many vitamins & other substances have been studied, some notable ones are Vitamins A,C, & E, which have many helpful properties (anti-inflammatory or immune actions, proteins to aid in wound remodeling, collagen synthesis & blood vessel formation, amino acids to build protein, & various minerals to support enzyme systems -Arteriolar pressure in LEs can affect skin integrity; process of aging can increase possibility of skin damage d/t skin thinning & loss of elasticity; smoking is risk factor for skin injuries

Conditions confused with arthritis

Fibromyalgia syndrome (FMS) chronic muscle (not joint) pain mostly seen in women, symptoms include restless leg syndrome, low back pain, or IBS; spinal stenosis; fractures or other traumatic injuries

Lower Extremity Amputation Prevention Program (LEAP Program)

Five main objectives -1. Reduction in osteoporotic fractures -2. Reduction in amputation rate -3. Reduction in pain r/t arthritis and other rheumatoid conditions -4. Reduction in injury rates from repetitive motion or overexertion -5. Prevention of workplace injuries Long-term goals -Development of program of program to minimize effects of pain & stiffness in arthritis -Integration of healthy lifestyle & avoidance of overexertion to reduce repetitive motion injuries -Ergonomic workplace (or home) design & education to prevent workplace injuries

Sexual Counseling Role

For Patient & Partner -One role of rehab nurse is education of pt w/ deficient knowledge; nurse should be informed, supportive, & respectful of pt; some of pt's needs might require referral to other team members or group classes; sexual partner also needs to be informed about expected alterations in body image & sexual functioning -Several decades ago, model called PLISSIT proposed by Annon; addresses logical progression in sexual counseling of pt, which starts w/ obtaining permission (P) for discussing than offering limited information (LI) followed by specific suggestions (SS) & later intensive therapy (IT) if needed For Children & Adolescents -Rehab nurse has responsibility to provide sexual education to children & adolescents w/ disabilities if parents can't do so; particularly true when children are confined to group settings that place them in vulnerable positions -Components of this education should include social skills r/t sexuality, specific information r/t age, & information about STD prevention -Age to introduce info about menses, male nocturnal emissions, puberty, STD, abstinence, & reproduction is between 8-11; between 12-18 other concepts such as sexuality within context of love & communication, birth control, responsibilities of sexual activity, & condom use should be addressed; nurse/other educator should be very direct about the consequences of unsafe sex

Bowel Training Programs

For Uninhibited Training Programs -Patients who have had a CVA, can usually return to continence w/ a good bowel training program; timing should be consistent & set based on habits & expediency; should be consuming a healthy, fiber-rich diet & plenty of fluids -Colon should be empty upon initiation of regimen; given stool softeners such as Colace or calcium, or some form of dioctyl sodium sulfosuccinate daily PRN plus suppositories on a PRN basis; if these do not work alone, a laxative (senna, phenolphthalein, casanthranol, or bisacodyl) may be added to facilitate peristalsis; since laxatives type 12 hours to be effective, that should be taken into account -Bulking agents (psyllium, alfalfa tablets, or calcium polycarbophil) should only be added if person has inadequate bowel tone, not an impaction -Nurse should keep bowel record & initiate program changes slowly For Reflex Neurogenic Bowel -Have upper neuron injuries & lack of cortical control of bowel functions; initially, SCI patients usually experience spinal shock & manual stool removal is generally indicated; once shock abates, bowel program can be started; since constipation between occasional episodes of diarrhea is primary concern, time for evacuation is generally lengthy -Once bowel sounds are heard & person has been put on suitable high-fiber diet, sufficient fluids, & some physical activity, they are given a daily suppository (try to have glycol based) to stimulate reflexive elimination; this suppository is inserted 15-30 minutes before scheduled elimination, but longer times may be needed -Eventually suppository use can be cut back to every 2-3 days; should use toilet is feasible; pt may have weak abdominal muscles indicating additional use of softeners, bulking agents, or stimulant laxatives; higher level of injury patients may experience potentially fatal hyperreflexia, which can be abated w/ rectal ointments For Autonomous Neurogenic Bowel -D/t lower spinal cord injuries, pt does not have spinal reflex responses; have decreased bowel tone & propulsive ability; thus they are incontinent between expulsions d/t inability to control external sphincter -Evacuation can be aided through use of suppositories placed relatively high against rectal wall and/or manual manipulation; main goal of bowel program is to establish a relatively firm stool texture by use of dietary fiber and/or bulking agents -During evacuation, person should sit on toilet, bend forward, & perform Valsalva maneuver (straining) & also massage (sometimes) abdomen to increase intra-abdominal pressure

Sleep card #2

Healthy Routines for Normal Sleep Patterns -Duration of good night's sleep ranges from over half a day (infants & toddlers) to 7-9 hours (adults); in order to achieve this on regular basis, one should try to go to bed & wake at same times daily; institution of bedtime routines such as warm bath, relaxation exercises, playing music, or reading is helpful; exercise done earlier in day, but not right before bed, promotes better sleep -A number of dietary or other practices should be avoided close to bedtime including excessive fluid intake, nervous system depressant alcohol, stimulants (caffeine or nicotine), spicy foods, & heavy meals; bed should be reserved for sleeping or sex; if can't fall asleep quickly, should get up & do something else Sleep Deprivation Causes -Leading causes: psychological in nature & include illness, stressors, or martial issues; sleep problems also often experienced by shift workers because of their work requires them to sleep at times not attuned to population at large or their natural circadian rhythm -Thus, in order to establish regular sleep pattern during daytime, they need to take additional measures, such as using blackout shades, sleep masks, & cool/quiet room; can also be deprived of sleep if in pain, have certain health issues (pregnancy), consume certain foods or meds prior to HS, & during jetlag Medications to Induce Sedation -Tricyclic antidepressants induce sedation in addition to managing depression or mood disturbances; some of these produce heavy sedation, such as amitriptyline, amoxapine, doxepin, & nortriptyline -Those taking SSRIs fluvoxamine or paroxetine also become quite drowsy as do those taking a2-adrenergic blocker antidepressant mirtazapine or serotonin inhibitor such as phenelzine -Other tricyclic antidepressants, SSRIs, & dopamine uptake inhibitor bupropion have less powerful sedative effects

Cranial Nerves

I-Olfactory bulb (smells) II-Retina (vision) III-Oculomotor IV-Trochlear V-Trigeminal (manages sensory & motor functions) VI-Abducens------3, 4, & 6 control eye movement VII-Facial (pain, taste, motor control of face and scalp muscles) VIII-Vestibulocochlear (hearing & sense of equilibrium) IX-Glossopharyngeal (multiple sensory, motor & PNS functions of ear & throat) X-Vagus (sensory, motor, & PNS of abdomen) XI-Accessory (controls skeletal muscles) XII-Hypoglossal (controls skeletal muscles)

Muscular dystrophy (MD)

Inherited medical condition with gradual weakening & wasting of skeletal muscles 3 major types -Facioscapulohumeral (facial & upper limb weakness) -Myotonic (1st noted in lower extremities & muscle relaxation is delayed) most common type in adults -Distal (late onset) affects hands, forearms, and lower legs

Mechanics of breathing

Inspiration -Diaphragm (attached to lower rib cage) contracts & draws down to decrease internal lung pressure while increasing intra-abdominal pressure Expiration -Occurs passively d/t elastic recoil of lungs Involuntary breathing -Controlled by central & peripheral neuronal areas and chemoreceptors Voluntary breathing -Controlled by distinct regions of cerebral cortex

Functional Mobility

Internal Factors -Ability to perform ADLs & instrumental ADLs; dependent on both internal & external factors; one internal factor is MS system, which forms basis of muscular strength, ROM, control of posture & alignment, & joint strength; both CNS & PNS affect functional mobility -CNS controls auditory, olfactory, tactile, & visual senses, which in turn affect things such as one's ability to feel pain, grasp spatial relationships, & maintain balance -PNS controls descending motor systems that influence reflexes, muscle tone, coordination, & other motor processes -Cognition perception: ability to acquire & assimilate knowledge, r/t CNS function & can be r/t impairments of hand-eye coordination, depth perception, inability to perform complex movements or neglect External Factors -Emotional & psychosocial circumstances of patient can influence their attention to self-care & amount of responsibility patient takes for self-care -Self-care may be discouraged or encouraged by patient's environment & technology accessibility; if patient functions in environments that are accessible & safe & they have assistive devices, functional mobility is more likely -Social & cultural beliefs of person as well as their economic situation can affect person's ability to trust & seek appropriate services to attain functional mobility; a person's total health status & age or stage of development can also influence attainment of functional mobility

Cognitive Defects card #3

Interventions & Outcomes in Other Rehab Settings -Primarily residential facilities --Promotion of personal safety of pt by controlling their environment, establishing a routine, monitoring behavior-goal is successful control of any behaviors that could lead to injury --Control of individual's tendency toward aggressive behavior through diet, absenting individual from any situation that can provoke aggression, ID of triggers & solutions, & education-desired outcome is self-restraint of pt --Assisting caregiver in adapting to patient's transfer to an institution by including caregiver in as many aspects as possible & establishing lines of communication --Promotion of patient's quality of life, including aspects such as medication administration, psychosocial support, encouragement of self-care activities-goal is satisfaction of both pt & family

Cognitive Defects card #2

Interventions & Outcomes in Subacute Rehab Units -Potential rehab nursing interventions & outcomes in smaller SAR units include following: --Establishment of comfortable, safe, & consistent environment & an orientation to reality for patient-cognitive recognition of people, places, & times --Promotion of attention span & focus by keeping outside stimuli at minimum & making sure patient has enough rest while slowly increasing difficulty of schedule-increased concentration needed for tasks --Use smells, sounds, touch, and/or visual aids to return to consciousness-show ability to be stimulated & adjust to their environment --Elevation of activity level in terms of both frequency & length through development of individualized program-increased tolerance to point of participation in daily activities --Promotion of family participation in care & understanding of patient's needs & cognitive deficits via support & education-family informed enough to assist in decision making & care & understand underlying process --Provision of available resources for family & patient to decide upon next level of care Interventions & Outcomes in Outpatient Rehab Settings -For rehab nurse in day care centers or at home include: --Promotion of safety in patient's home through use of aids, adaptive equipment, grab bars, etc.-lack of evidence of any physical harm --Establishment of readiness of the caregiver by evaluating their abilities & working w/ caregiver on planning & resources-capable of assuming full responsibility in home setting --Encouragement of good care by caregiver by helping them set up a plan, supporting them, & anticipating their needs-recognition of behavioral changes & needed services --Monitoring caregiver's health as well to make sure they can deal w/ stress involved & direct caregiver to support services if needed --Promotion of normalization & integrity of family through any strategies that optimize family interactions & support family during crises --Provision of resources to enhance & promote wellness, recuperation, & rehabilitation of patient including stress reduction, exercise, & education --Enhancement of social skills in patient through techniques such as group therapy, role-playing, positive feedback

Dysphagia card #2

Interventions for Feeding --Sit down w/ pt in quiet, well-lit room during feeding & constantly be attuned to signs of aspiration or respiration or voice changes -Specific recommendations for body position of pt w/ dysphagia while eating & swallowing --Seated upright during & for about 30 minutes after meal to prevent reflux; should place their arms on table for support; head is flexed downward & chin tucked in to protect airway & avoid aspiration --Nurse may need to place palm of hand on forehead to support pt's head; should consume meal slowly, taking 45 minutes & allowing sensory awareness of food --At first, only small bites of soft foods are suggested; food placed firmly w/ teaspoon toward back of tongue; if paralyzed on one side, food is placed on unaffected side --May be necessary to take spoon out & have pt move food back or check & possibly physically seal lips to initiate swallowing reflex Feeding Tubes -Indicated when dysphagia pt can't obtain nutrition orally & should be removed once they can re-establish normal nutrition -Often used initially during tx but should not be used long term -Fine bore NGs recommended; if need for more than month, usually surgically positioned -Problems: irritation, swelling, bleeding, aspiration, peritonitis, diarrhea, & tube displacement -Some meds may be administered through tube, need to checked daily for evidence of edema or dehydration -Characteristics of fluid & stool output need to be evaluated daily as well; less frequent measurements should include chemistries, serum electrolyte levels, BUN, blood counts, & weight Dietary Modifications & Med Administration -Liquid & food consistencies are important for feeding dysphagia patients & should be selected according to nature of swallowing disorder; ADA has standardized classes for both --Thin (water, broth, milk, most juices, supplements, coffee, tea); nectar-like (nectars & prune juice); honey-like; & spoon thick; later 2 refer to consistencies created through use of thickening agents -Food consistency is divided into 4 levels through which patients proceed --Level 1: pureed, do not necessitate much chewing --Level 2: mechanically changed to be consistent & semi-solid & therefore, require limited chewing capacity --Level 3: soft by require more chewing --Level 4: normal foods w/ solid consistency -Constipation can be averted through addition of bran or prune juice -Meds given in custard or gelatin product

Ear & Hearing card #2

Interventions for Hearing Loss -Several available hearing aids that amplify sound (acoustic aids), utilize skull bones to transmit sound (conduction aids), or functionally replace the cochlea through implantation (cochlear implants); American Sign Language (ASL) is official foreign language in our culture that is useful to communicate; may use internet for correspondence; also a number of assistive listening devices, computer aids, & telephone configurations; assistive listening devices include microphones, headphones, pocket talkers, & systems that can be used on group settings such as infrared connections or permanent installations -There are devices that can be connected to telephones to amplify sound, TTYs & TDDs (teletypewriters & telecommunications devices for the deaf), & relay services using these TTYs & TDDs; also several automatic speech recognition systems (ASR systems) that use microphones to pick up speech & interpret it on a computer screen; alarm systems are available w/ visual or vibrating indicators for doorbells, telephones, & smoke alarms Communication w/ Hearing Impaired Individual -Caregiver needs to first get their attention, needs to face & stand or sit near them during communication, speaking clearly & distinctly, using repetition, hand gestures, & visual aids if needed; needs to make sure they understand what has been said -In rehab setting, they must be clearly informed about procedures, which means that ASL interpreter may be needed if they use that language; nurse & interpreter both need to face pt & maintain clear visual field while communicating w/ the patient

Burns card #3

Interventions for impaired physical mobility -Appropriate positioning can be important to preserve elements of mobility -Goals of positioning during acute phase: edema minimization & joint alignment maintenance w/ tendon balance to avoid contractures -Main emphasis during rehab stage: contracture prevention --When lying flat: use various pillow, neck roll/brace, knee braces, and/or footboard with pad --A daily routine w/ a full set of ROM exercises is important --A splint may be needed to maintain joint structures -A customized compression garment should be worn constantly for up to 2 years to prevent and/or reduce hypertrophy scarring Other diagnoses & interventions -R/t rehab phase are r/t pain management, ineffective health maintenance, psychosocial adjustment -Chronic pain: managed through prescribed meds, making pt comfortable, & implementing alternative techniques -Rehab nurse can help with ineffective health maintenance by educating them about lifestyle changes & self-care techniques -Psychosocial issues: disturbed body image, social isolation, & changes in family dynamics -May experience post-trauma syndrome (PTS) prompted by injury flashbacks -Depending on severity & burn location, return to sexuality may be difficult or going back to work in previous capacity may be affected -Nurse can serve as support & educational resource

Musculoskeletal problems & disorders

Lab & diagnostic tests -RBC, WBC, cultures, CRP, ESR, electrolytes, BUN, serum creatinine, alkaline phosphatase, creatinine phosphatase, uric acid, joint fluid analysis -DEXA (for bone density), contrast discography, radioactive scintigraphy Nursing dx, tx interventions, goals -Dx: pain, activity intolerance, self-care deficiency, impaired mobility, poor body image -Tx: therapy Secondary musculoskeletal problems -Most common are CVAs and SCIs -CVAs: rotator cuff tears, spastic shoulder muscles, nerve impingement -SCIs: spasticity, overuse syndrome of shoulders, bone remodeling d/t loss of calcium, deposition of new bone in joints, muscle atropthy Common musculoskeletal problems -Kyphosis: permanent hunched over curving -Lordosis: inward curving of lower back -Scoliosis: marked sideways spine curvature -Genu varum: outward knee bowing -Genu valgum: inward bowing or "knock-knees"

Therapeutic Positioning card #2

Lower Extremity Amputees -Present unique positioning issues; positioning aids such as pillows under hip, knee, back, or between thighs should not be used when lying down; bed end should not be raised; legs should not be allowed to spread outwards while patient is on back;residual limb should not lean into affected one nor should it be allowed to rest on side of bed or chair -Upper body generally strengthened using overhead trapeze; when seated, unaffected limb should never be bent & should instead be extended straight & propped up w/ leg rest or limb board; when standing, should not be allowed to support weight on walker bar or crutch grip Movement While in Bed -Need to turn, change positions to alleviate pressure, move to different spots on bed, if possible, sit up in bed; patients capable of assisting in these positions changes can use side rails, cords attached to various areas, or overhead trapeze; if caregiver are needed to move patient, bed needs to be locked into place at hip height; usually 2 people are needed to move patient, one who supports patient's upper back w/ 2 arms & the other who positions arms up lower back; each stands w/ slightly bend knees & one foot in front of other (good body mechanics) -One strong person can help patient to move if latter assists or if caregiver approaches task piecemeal; in order to turn patient, caregiver should stand on side to which patient is to be turned & swiftly transfer weight from one leg to other, using hand pressure behind shoulder & hips

Limb amputation

Lower extremity: below-the-knee (BKA), above-the-knee (AKA), foot/ankle (Syme's), foot below ankle bone (Hey's or Lisfranc's), and hip disarticulation at hip joint Hemicorporectomy: rare critical procedure in which half of the body is removed including pelvic & lumbar areas Upper extremity: Hand or isolated digits, arm above elbow (A/E), arm below elbow (B/E), shoulder disarticulation at shoulder joint Tx: after surgery, residual limb is wrapped with bandage to shape stump & decrease swelling; prosthesis or artificial limb applied after residual limb is healed & swelling is minimal

Cardiac rehabilitation card #4

METs -MET=metabolic equivalents, one is = to 3.5mL O2/kg/min (O2 concentration needs in terms of body weight while at rest) -2-MET activities require twice the O2 & energy -One goal of cardiac rehab is to eventually increase number of METs at which exercise is done; suggesting improvement in cardiac parameters -Elderly patients or those with chronic or restrictive conditions usually work in lower MET ranges Maintenance Phase -Starts 2-3 months after cardiac event & should continue throughout life; can be done at hospital or clinic, in community-based exercise facility, or at home -A big part is evaluation for & facilitation of return to work; treadmill test is done to determine # of METs at which patient can operate -Relevant nursing diagnoses: ineffective coping, grieving, unsuccessful role performance, social isolation, noncompliance -Interventions: continued rehab cardiac care & patient support (emotional support, support groups, counseling, anxiety reduction, role promotion, & family integration) Evaluation of Services -Evaluate both process & outcome -Program standards & desired competencies for professionals are available for comparison; nursing outcomes expected for assessment of end product --Some nursing outcomes apply to all phases such as cardiac disease management & control of risk to CV health --Many apply primarily to inpatient phase (circulation status, fluid balance, response to medication, & cardiac tissue perfusion; others are relevant later (depression control & adherence to health seeking behaviors) --Some change focus: patient should rest during inpatient phase but concentrate on energy conservation later -Many studies show that cardiac rehab can improve functional capacity & decrease mortality rates

Spinal Cord Injuries (SCIs) card #2

Major SCI Syndromes -ASIA has characterized 6 major SCI syndromes --Central cord syndrome: caused by neck hyperextension resulting in C-region injury; clinically, pt's UEs weaker then LEs, sacrum not affected, & may have bowel/bladder problems --Anterior cord syndrome: front of spinal cord is compressed (usually through flexion or bone fragments) leading to sensitivity to pain & temperature & motor function are lost --Brown-Sequard syndrome: penetration or some other trauma occurs on one side of spinal cord; nerve endings are damaged, resulting in loss of motor function & an inability to feel deep pain on injured side plus loss of sensitivity to light touch, pain & temperature on other side --Conus medullaris syndrome & cauda equina syndrome: result from trauma to sacral & lumbar nerve roots, resulting in involuntary bowel, bladder, & lower limb motions; basic difference between two is area of sensory preservation --Posterior cord Syndrome: rare lack of all dorsal column function Spasticity & Skin Integrity Recovery Goals -2 major areas of concern in tx plan for patients w/ upper motor neuron SCI; spasticity occurs in majority of these patients in acute rehab timeframe after resolution of spinal shock; it is nurse's responsibility to help ID what stimulates this behavior (often certain body alignments), minimize activator at that time, & develop plan for management after d/c -ROM & stretching exercises are generally recommended; pain may be managed w/ various anti-spasmodic drugs, & other measures, including surgery, may be required -Maintenance of skin integrity is issue for all SCI patients because they lose mobility, sensitivity, & automatic functions, resulting in increased risk for pressure ulcers; addressed through use of specialized sleeping surfaces, frequent positioning, & weight-shifting changes

Pain card #2

Malignant pain -Results from either compression of nerve endings by tumor, associated infections, or liberation of prostaglandins; always treated pharmacologically, but drug of choice depends on amount of pain; aspirin or NSAIDs are used to tx mild pain -Moderate pain-give opioids or additional aspirin & NSAIDs; severe pain, opioid dose & dosage schedule are generally augmented, if pain persist-other agents are added (blocking agents, spinal administration of an opioid, aspirin, NSAIDs, & surgical intervention) Chronic & Intermittent Nonmalignant Pain -Causes are debatable; many feel that pt develops cycle of chronic pain through initial protection & immobilization of damaged area that leads to scar tissue development, functional loss, inactivity, compensatory actions that promote further pain, & sometimes depression or addiction -Most prevalent in young children, usually w/ specific diseases such as juvenile RA or sickle cell anemia; pain in children hard to pinpoint since they have difficulty verbalizing it; pain thresholds tend to increase w/ age, & older individuals who have developed potentially painful disorders over time tend to underestimate pain -Managed using multidimensional team approach incorporating behavioral modification, use of local therapies, body mechanics, & other strategies; this multifaceted approach is also used to manage phantom limb pain after loss of a body part; intermittent nonmalignant pain is usually managed pharmacologically Nonpharmacological pain management tools -Can be alleviated through application of warm compresses or in cases involving swelling, cold packs; comfort levels can often be raised simply by repositioning pt or providing physical stimulation, such as vibration, pressure application, or massage to relax patient -Focus pain & enhance relaxation: cognitive distraction w/ music or reading, imagery techniques, aromatherapy, therapeutic touch methods such as Reiki or massage, or hypnosis -Several methods that use electrical stimulation, including transcutaneous electrical nerve stimulation (TENS) to peripheral muscle fibers to block pain impulses & acupuncture, which involves insertion of many small needles (sometimes in conjunction w/ electrical current to block pain) -Biofeedback monitors electrical impulses or skin temperature as a tool to teach patients how to relax; herbal medicines are sometimes used, but attention should be paid to harmful SEs

Intellectual/developmental disabilities card #2

Mental illness & behavioral disorders -Prevalent in pts with I/DD problems -May be a way to get attention or a way to cope, should rule out physical problems 1st -Dx: By psychiatrist or psychologist -Assess by using family/caregiver interviews, behavior surveillance, medical exam, psych consultation, & behavioral scales -Meds: antipsychotics (Haldol or clozapine), SSRIs (fluoxetine or bupropion) for depression, antianxiety (buspirone for stress disorders), mood stabilizers (lithium), anticonvulsants for bipolar Associated, comorbid, & secondary conditions -Seizure disorders prevalent as patient ages, communication difficulties, language delay, behavioral & sleep issues are often d/t SEs of meds given for ADHD -Increased risk for vision & hearing losses * defects of sensory processing or integration (especially w/ autism or fragile X) -Secondary conditions: substance abuse, obesity, dental hygiene issues, & self-abuse -Specific to particular diseases: --Cerebral palsy-muscle contractures --Down syndrome-heart disease

Language card #2

Microanatomy & Neurophysiology of Linguistics -Linguistics or language functions are directed by L hemisphere of brain in vast majority of individuals; on simplest level there are 3 major neuroanatomical areas involved w/ language function, angular gyrus, Wernicke's area, & Broca's area; it is believed that angular gyrus, located @ temporoparietal occipital intersection, relates visual impressions to spoken word -This information is then transferred to Wernicke's area in back of superior temporal gyrus where sound pattern recognition occurs; adults learning a 2nd language utilize another brain region called Broca's area; there is evidence that other parts of brain are summoned in language processing-for example, secondary region of auditory cortex appears to be utilized by hearing impaired individuals for sign language usage Broca's aphasia & Transcortical Motor Aphasia -Aphasia refers to any type of linguistic deficit precipitated by brain damage; people w/ Broca's aphasia generally comprehend spoken word, but many other functions associated w/ verbalization are impaired; this aphasia results from brain damage at or near Broca's area & it is primarily characterized by agrammatism or syntactic loss as well as partial or total inability to move R side -These individuals do not have fluent speech, & abilities to read, write, repeat, & name objects (sometimes) are impaired; they may have trouble responding to verbal commands w/ L side of face or L arm as well; Transcortical motor aphasia often mimics Broca's aphasia, but in this case, repetition capabilities are preserved & site of damage is generally near Broca's area or supplementary motor area (SMA), causing a disconnect between the two

Oncology rehabilitation

Mission -Program should be broad, collaborative, & interdisciplinary -Inherent to good cancer care, should be available at all stages of cancer, & should involve both patient & family -Should be accessible & reimbursed in a timely manner & managed & delivered by competent professionals (RNs who are informed & certified in either oncology or rehab specialties) Interventions & goals -Focus is on improvement of patient's quality of life, provision of services that will increase satisfaction of patient & family, & cost management -NU diagnoses: fatigue & disturbed body image --Fatigue: prolonged feeling of exhaustion & incapacity to perform at normal levels; common causes are chemotherapy, radiation therapy, medications, anemia, metabolic changes, & depression -Interventional roles of nurse: sleep enhancement, provision of emotional support/counseling, & energy management --Disturbed body image (loss of breast): can be decreased w/ support & counseling -Quality of life interventions: bladder/bowel management, family encouragement, health education, & pain control -Oncology rehab can serve as preventive, supportive, or palliative roles; not just restorative

Postsurgical complications after musculoskeletal surgeries

Monitor circulation, sensation, movement, and firmness; look for signs of swelling or bleeding Watch for compartment (infection, deformity, amputation if not caught) & fat embolism (hypoxia, cardiac problems, chest pain, AMS) syndromes

Repetitive motion injuries

Muscle fibers tear & form relatively inelastic scar tissues Sports injuries are among most common; runners-calf or Achilles tendon injuries, knee pain, shin splints, stress fractures Job related injuries: most common is carpel tunnel syndrome-pressure on median nerve within carpel tunnel of hand causes lack of sensation or tingling & eventual muscle wasting Repetitive or sudden hand movements -May cause ganglion cysts or swollen tissue pockets

Sleep card #3

Natural & Dietary Substances -Amino acid tryptophan can induce sleep if ingested on empty stomach prior to bed; milk & potatoes are good sources, but synthetic not recommended d/t possible safety issues -Melatonin, hormone derived from serotonin, secreted from pineal gland in brain; involved in both pigmentation & regulation of biorhythms w/ maximum amounts available at HS; in herbal supplemental form, being as sleep enhancer -Other herbal supplements for sleep: valerian root, lavender, & chamomile, & St. John's wort (antidepressant) among most promising but have not been definitively proved to have value as sleep aids or been investigated for sleep pattern effects -Controversial herbs include hops, lemon balm, jujube, or narcotic opium poppy (utilized as sedatives) Health Care Issues -Pain & meds used to relieve it can affect sleep quality; narcotic analgesics do not appear to affect time spent sleeping, but do disrupt both deep sleep & REM sleep; causes sleepiness during day & agitation during sleep; cardiopulmonary problems manifest as general or prone SOB & associated issues such as sleep apnea & HTN -In sleep apnea, muscles in upper airway relax & collapse causing O2 levels to be depressed; eventually, they wake up periodically gasping for breath; those w/ urinary frequency or urgency issues, whether d/t infection, diuretic use, or innate physical problem, awake during night & sleep cycle is disrupted -Position changes during sleep & spasticity in pt's w/ musculoskeletal problems can cause arousal & changes in sleep cycle; pt's w/ Alzheimer's disease & alterations in cognition have impaired circadian rhythm, which causes nocturnal sleeplessness & other problems; older people often have difficulty getting enough deep & REM sleep because later sleep stages shorten w/ age

Language card #1

Normal Development in Children -Up to about 1 year, most are in language less stage; newborns express through reflex sounds such as crying, screaming, or whimpering; by 4 months old, infant can generally laugh, voice vowel, & some consonant sounds, & produce repetitive babble or alternating consonant & vowel sounds like "dada" -In next months, other consonants appear & pitch of infant's voice begins to resemble adult speech; most infants reach next beginning semantic stage 2 by age 8 months to 1 year; at this stage, infant can understand a few words & in next few months or progresses to partially intelligible speech, particularly single words about actions, objects, or location -Stage 3, the semantic language or substantive word stage, is usually reached in phases to about 75%; child's vocabulary increases to several hundred words, & they begin to understand syntax & spatial relationships; most children able to understand syntax (stage 4) by about age 3 & certain remaining distorted sounds are mastered over next few years Speech Components & Language Production Levels -Speech is both expressive & receptive; in other words, normally is either produced or comprehended; both aspects are necessary for effective communication; also level of language construction -Most basic level is automatic language (routine response like prayers or curse words); imitation is more advanced form of language because it entails processing of what is heard before a trite or imitative response is given; highest plane of language formation is called symbolic language, which involves independent creative intention, correct syntactic organization, & application of rules of tense & plurality

Pressure Ulcers card #1

Norton & Braden Scales -Both are risk assessment tools for development of pressure ulcers; each rates certain parameters & adds up values to determine risk -Norton scale: uses 5 factors, each valued from 1-4 (physical condition, mental state, activity level, mobility, & degree of incontinence) -Braden scale: rates amount of sensory perception, skin moisture, activity level, nutritional consumption, friction, shear, & capability for changing & controlling body position; each parameter is rated from 1-4 except for extrinsic factors of friction & shear (rated 1-3) -For both scales: all ratings are added & lower scores indicate greater propensity toward development of pressure ulcers -Patient's sensory perception or capacity to feel pressure-related pain & mobility or ability to change body position are similarly rated to Braden scale; each is assigned rating from 1-4 for (completely limited or immobile, very limited, slightly limited, or without impairment or limitations); moistness of skin is also rated from 1-4 (constantly moist, very moist, occasionally moist, or rarely moist); activity level rated 1-4 (bedfast, chairfast, able to walk occasionally, or walks frequently); nutrition or food intake pattern rated 1-4 (very poor, probably inadequate, adequate, or excellent); susceptibility to friction or shear rated as 1-3 (a problem, a potential problem, or no apparent problem); ratings then added together to predict pressure risk w/ lower scores (possible of 23) indicate increased probability Common Areas for Pressure Ulcers -Can occur anywhere there is soft tissue compression; in adults, some of more common sites are sacrum bone at base of spine (especially w/ SCIs), calcaneus, chin (d/t cervical collars or tracheotomy or ET tubes), ischium of pelvis, & trochanter between thigh & pelvis -However, depending on how they are positioned, many more pressure points are possible -Children: tend to develop pressure ulcers from sitting or on their feet or UEs; also prone other disruptions of skin integrity (diaper rash followed by skin tears & IV leakage of blood or fluids)

Sleep card #4

Nursing Assessment of Sleep Pattern -Sleep assessment should be included when evaluating patients; Ask questions (also use questionnaires) as well as usually observing hourly sleep pattern; should question about difficulties falling asleep & during sleep & whether they feel refreshed upon awaking; ask about regular time schedule for doing to sleep & waking up, if they use meds for inducing sleep, & if/when they consume alcohol or stimulants -Questions addressing daytime drowsiness or napping, frequency & reasons for getting up at night, whether they can go back to sleep should be asked; hourly objective sleep evaluation important because nurse can document how long they sleep & whether they get up during that period in order to adjust factors that might facilitate sleep (room temp or noise levels) Parasomnias -Medical conditions/events that disturb sleep patterns or disorders of arousal or disorders of sleep-wake transition; somnambulism (sleepwalking) is prime example of the latter disorder in which person is awake enough to be active but not really aware of actions -Interventions: benzodiazepines (diazepam) & pre-sleep relaxation; frightening dreams or nightmares during REM sleep are parasomnias; also included are nocturnal leg cramps in healthy middle-aged or elderly & restless leg syndrome (RLS); RLS is relative misnomer because is also affects arms & is characterized by increased surface sensitivity in extremities, which can cause bursts of movement during sleep Dyssomnias -Abnormal sleep patterns; 2 types: insomnia-inability to fall asleep or remain asleep long enough to be rested & hypersomnia-extreme sleepiness & extended periods of sleep -Insomnia: can have myriad of underlying causes --Interventions: environmental control, relaxation measures, management of neurological systems, med administration, & toileting assistance -Hypersomnia: generally caused by some sort of brain disturbance (lesions in hypothalamus, ICP, encephalitis, depression, or metabolic abnormalities such as hypoglycemia) --Narcolepsy: variant of hypersomnia where individuals can sleep deeply at brief & odd intervals & may have hallucinations or difficulty moving

Cognitive Defects card #1

Nursing Diagnoses -4 main nursing diagnoses indicating cognitive defects --1st: disturbed thought process, a disturbance of cognitive function relative to expected age expectations; characterized by memory issues, lack of decision-making abilities, inattention, & can be caused by a variety of neurological problems as well as electrolyte imbalances or infection --2nd: chronic confusion, progressive worsening of intellectual processes & behavior, generally sign of dementia, stroke, or other injuries & is characterized by disorientation, altered personality, & memory problems --3rd: impaired memory w/o other symptoms; may be caused by other factors such as stress, CHF, & neurological disorders; patients are forgetful, particularly in terms of recent events --4th: impaired environmental interpretation syndrome describes people who have been unable to orient themselves to their environment over a period of at least 3 months & are chronically confused & unable to concentrate or reason; this syndrome often occurs in Alzheimer's, Parkinson's, & Huntington's disease Interventions & Outcomes in Acute Rehab Units -Appropriate nursing outcomes & interventions w/ cognitive deficits in acute rehab units include following: (intervention-desired outcome) --Promotion of cognitive function through use of testing, aids, & stimulating activities-execution of complex mental processes --Encouragement of appropriate decision making by identifying choices, providing support, & introducing increasingly difficult tasks-ability to make decisions between alternatives --Establishment of appropriate thought control by reinforcing appropriate & discouraging unsuitable behavior-establishment of appropriate thought processes & subject matter & perception thereof --Promotion of correct information processing through conversation & discussion-demonstrates ability to acquire, organize, & use information --Stimulation of memory through use of repetition, memory games, group training programs-recovery & report of previously gathered information --Safety promotion by ID of risk factors & providing safe environment-no falls --Control of aggressive behavior through ID of precipitating factors & development of behavioral management plan-practice of self-restraint

Urinary Incontinence card #1

Nursing History -Should include characteristics of incontinence & frequency of toileting during day & at night\ -Characteristics: frequency timing, onset, associated degree of urgency & leakage, & pad usage; nature of loss & situations that prompt it -Incontinence d/t stress, urge, or overflow are characterized by spurts, streams, or dribbling respectively; leakage during activity or expulsion suggests stress while failure to reach toilet=urgency -GU hx & associated symptoms should be noted; hx of childbirth, pelvic or lower urinary tract surgery, periodic infections, & previous treatments should be included -Hx of symptoms such as ability to sense fullness or voiding, facility to delay emptying, presence of post-urination dribbling, slow or interrupted voiding, pain w/ urination, or bloody urine should be noted; later 2 suggest infection -Medical hx should also be taken as well as meds, pt/caregiver observations, & home setup Nursing Interventions -In toileting self-care assistance, simply assists w/ urine elimination; urinary elimination management goes further by providing means to maintain most advantageous pattern of elimination by assessing & monitoring pt's voiding -If needed, catheterization into bladder for drainage on temporary, permanent, or intermittent basis; also monitor for signs of infection & catheterization volumes -Urinary bladder & urinary habit training --Bladder training: techniques to improve bladder function in pt w/ urge incontinence --Habit training: institution of regular voiding patterns to discourage incontinence -Urinary incontinence care: support for maintaining successful continence & perineal skin care; urinary retention care: any method of helping pt alleviate bladder distention Medical hx & Physical exam -Should include documentation of renal diseases complaints, & neurological diseases --Also incorporate history of acute illness, DM, depression or other psychological problems, malignancy, & CV disease -Physical exam: inspect abdominal, genital, & rectal regions for masses & skin abnormalities --Abdomen: evidence of distended bladder or tenderness above kidneys --Genitals: signs of infection or evidence of abnormalities --Rectal: presence of fecal impaction, checking prostate size, checking sphincter tone -Functional assessments: mental/mood status; manual dexterity, gait & balance; neurological exam; & stress testing w/full bladder while seated or standing -Test bulbocavernosus reflex by grasping glans penis or glans clitoris to eval anal contraction -CHF evidence is also relevant

Bowel Program

Nursing History & Physical Exam -Needs to include questions about pt's present & past bowel routines, such as frequency, stool texture, degree of incontinence, perception of filling, ability to control BMs, & laxative use; dietary & drinking habits, particularly amount of fiber ingested -Take note of meds, including those who have SEs or actually elicit constipation; presence of bowel syndromes or other disease that can effect bowel motility or secretions should be included in hx -Should test to determine neural function in bowel area; check abdomen (inspection, auscultation, & palpation) for distention & movement, bowel sounds, muscle function, & presence of impacted stool -Rectal exam also done to appraise tone & strength of anal sphincter & to look for lesions or stool Dietary, Fluid, & Exercise Requirements -Most important dietary requirements is high fiber; fiber binds to water in intestine to avoid later overabsorption, speeds transit, & makes stool consistency both bulky & pliable; bulking can assuage diarrhea & softening can preclude constipation; can be supplied by wholegrain cereals or breads, nuts, fruits w/skins, & leafy or leguminous vegetables -Diet be varied & include nutrients; should drink plenty of water (several quarts) & other liquids that can stimulate elimination (prune juice, hot coffee, or tea); this will keep stools soft -Exercise augments muscle tone & assures quicker establishment of bowel function

Gerontological rehabilitation card #1

Nursing process r/t care planning -Generally deal with patients 65 or older -Performs complete physical assessment, also be attuned to signs that can influence other health issues -Med history is important (may be taking meds and other non-script preparations that can interact, be outdated, or are not taken at proper dosage) -Ask about ADLs, look at suitability of home & community environment Physical assessment -Height & weight, general appearance -Head: reflexes, acuity, & visual aspects of eyes, ears, nose, & throat -Cardiac: take BP and pulse, feel carotid & jugular veins, check for pedal edema -Resp.: lungs sounds, dyspnea, breathing rhythm & expansion -Abd: firmness, pain, circulation, liver tenderness, & bowel sounds -Rectal & pelvic exams, pelvic floor strength important for incontinence evaluation -Screen for balance, gait function, ataxia -Cognitive: comprehension, short term, long term memory, ability to express emotion, MMSE & Geriatric Depression scale -Skin examination Diagnoses & desired outcomes -Common dx: adult failure to thrive & common nursing outcomes are r/t improvement of nutritional (hydration & wt management) or health status, cognitive improvement, & social involvement -Another common dx: risk for injury with most important risk prevention r/t reducing falls -Disturbed sleep pattern & chronic pain; addressing physical & emotional needs (elimination patterns & anxiety) can improve disturbed sleep pattern; need to make patient comfortable & symptoms controlled to alleviate pain & stress/depression -Ineffective coping: improve by helping patient learn to cope & get sense of control; may present with acute or chronic confusion (acute-temporary or controlled factors, but chronic-more permanent problems)

Language card #4

Other Types of Aphasias -Conduction aphasia: primarily characterized by intact verbal comprehension & fluent but highly paraphrasic or repetitive language production; caused by damage to supramarginal gyrus of brain; writing ability is generally impaired & there may be other sensory losses -Most prevalent type of deficit is anomic aphasia, which is primarily characterized by inability to locate correct word to use while most other language facilities are intact; caused by injury to L temporoparietal junction region if severe, but mild cases can result from many types of damage -Pure word deafness: inability to comprehend speech while retaining most other language functions; here repetition is also affected generally, & injured part of brain is usually superior temporal region of importation of both superior temporal gyri; imaging studies show some degree of spontaneous recovery from aphasias after injuries is possible Other Language Problems -Dyslexia: common problem characterized by impaired ability to understand written language; many areas of brain have been found to contribute to dyslexia; several types of language delay or general communication problems can be identified in childhood; many problems can be connected to chromosomal abnormalities -Delayed language development in association w/ global intellectual disability can be found in Down syndrome children -Angelman's syndrome: characterized by no speech plus intellectual disability; language postponement can be associated w/ developmental aphasias; in children w/ infantile autism, communication is absent or highly abnormal

Burns card #1

Pathophysiology -Characterized in terms of thickness --1st degree: superficial, penetrating only epidermis --2nd degree: deep partial thickness with epidermal & dermal involvement --1st & 2nd degree hurt d/t severed & exposed nerve endings & generally blister, but heal because epithelial cells are not actually destroyed --3rd degree: full thickness, destroy epidermis, dermis, nerve endings, & SQ tissue, muscles, & bone (sometimes) -Eschar: thick, dry scab made of denatured protein develops over injured area -1st physiological reaction is vasoconstriction of capillaries followed by vasodilation & plasma d/c -Within a few days, cells die & there is considerable fluid & heat loss; clotting may occur & metabolism steps up -Local sepsis likely, which can destroy tissue & increase burn thickness; may go into burn or hypovolemic shock from fluid leaking into area tissues, which become edematous -Hemodynamic changes can cause systemic problems Burn care & Wound healing -1st phase: emergent or resuscitative stage, generally performed at injury site or in ER, in which critical issues are addressed --Can involve airway clearance, fluid replacement, infection control procedures, & general support -2nd phase: acute stage-time from burn injury to stabilization of all relevant systems, wound care, control of infections, nutritional support, & maintenance of functionality & mobility -Wound healing depends on thickness of burn --Partial thickness: heal through marginal cell migration to form fresh epithelium in about 2-3 weeks --Full thickness: heal through clearing of wound area through phagocytes by WBCs, collagen secretion, & epithelial cell migration to restore capillary networks & circulation -Rehabilitative phase: addresses issues such as life & workplace reentry, body image, minimizing muscle tightening from scarring, & maintaining ROM & strength

Assistive Devices for Ambulation card #1

Patient Preparation for Use -A physical therapist often plans isometric & therapeutic exercises to prepare patient for standing & ambulation; nurse often implements these plans; preambulation exercises usually include isometric exercises to strengthen trunk & extremities, adapted sit-ups & push-ups done in bed, exercises for the arms done in seated position, & passive standing activities if possible -Passive standing can be assisted through use of either tilt table or standing frame; patient strapped to a tilt w/ feet on footrest; table then adjusted from 15-20 degree angle at small increments until patient can stand for about 10-30 minutes; important to measure parameters such as BP, HR, & swelling in lower limbs prior to beginning & during use of tilt table -Standing frame or table, which uses stabilizers in front of & behind key support areas (such as knee, abdominal, pelvic, & buttock regions) to directly move patient from sitting to standing position Crutches -Need to be selected specifically for patient by physical therapist based on individual's needs, height, & weight; canes are intended for use by patients w/ limitations only in LEs; crutch selected to support body weight at handgrip while flexing elbow @ 30 degrees so that armpit is not used for support -4-point alternative, 2 point, or swing gait patterns are usually recommended for patients w/ limited strength or balance, better balance, or inability to bear weight on one leg respectively; in 4 point pattern, axillary bar held against chest for lateral support; step pattern uses opposite foot after putting crutch forward followed by other crutch & foot; 2-point pattern, moves both crutches forward & then walks by moving opposing crutch & foot simultaneously; in swing gait, both crutches are moved forward while patient bears weight only on unaffected side & then either steps up to crutches or good leg is swung through to position ahead of affected limb

Recommendations for goals & ADLs card #1

Patients w/ Limited ROM & Strength -Such as those w/ arthritis, should incorporate measures into daily routine that conserve energy, lessen pain, & offset reduced capacity for mobility -Modifications for daily living such as use of following: shoe fasteners, stocking aids, & easy closers (large buttons or Velcro): assistive devices for reaching; dietary aids (utensils w/ large handles, cup modifications such as attachable straws or bottom suction cups) easily opened jars or openers, & foods that have been pre-prepared & stored in containers; devices that enhance grooming & toileting (electric toothbrushes & razors, tub grab bars & handheld showerheads, carrying bags attached to walkers) Patients w/ Hemiplegia -Partial or total inability to move one side, usually d/t CNS damage; primary goal is to make best use of affected side w/o causing frustration or engaging in unsafe maneuvers; plan should include exercises that increase pt's strength, ROM, balance, cognition, & perception; patient can follow dressing procedures w/ assistance from a helper; if have balance issues, can dress while seated or braced against door or wall frame -If have problems recognizing clothing or performing complex tasks required in dressing, helper can use tactics such as having pt feel clothing, name parts of it, engrain methodical procedures for task performance, & employ techniques to stimulate awareness & use of affected side -Eating recommendations: anything that will prevent accidents & add to pt's goals for improvement; especially important to provide safe environment in bathroom w/ devices such as shower seats, grab bars, & ramps -Good illumination is important; personal care items that can be used w/ one hand should be available

Recommendations for goals & ADLs card #2

Patients w/ Low Vision or Cognitive Defects -Safety is main issues; personal care, food-related items, furniture, & medications should be presented in consistent environment or pattern; direct lighting should be selected to reduce glare & maximize contrast; if blind, services available to assist w/ most ADLs -In individuals w/ cognitive defects, again providing a safe environment is paramount while preserving dignity; may have problems w/ memory, lack of attention, problem-solving ability; thus, consistency is important in rehab plan of these patients -Rehab plans should include: incorporation of cues or memory aids, close management of environment, reinforcement of behavioral patterns, & consideration of familial & cultural values Patients w/ Lack of Coordination or Amputated Limb -Main goals are safety & independence within environment that lessens anxiety; ADLs should be performed slowly & methodically in order to conserve energy; good tactic is to prop upper limbs on solid surface for stabilization; tend to need gait training -Should slide items instead of lifting them; recommendations w/ upper limb amputations are similar to those w/ hemiplegia; if lower limb amputated, then will need specialized dressing techniques such as bridging while lying down or dressing while seated or rolling on bed; may need to use devices designed to put on shoes or socks

Swallowing card #2

Physiological process -Food undergoes an oral preparatory phase in which it is taken into mouth, mixed w/ saliva, & processed according to consistency; tongue than compresses against hard palate & moves food toward back, near oropharynx-this is known as the oral phase -Both oral preparatory & oral phases are voluntary, w/ open airways & nasal breathing -In pharyngeal stage, mass of chewed food is propelled down toward esophagus along pharynx through a series of reflex actions; airway or larynx is cut off less than a second by downward angulation of epiglottis & entry to esophagus is controlled by cricopharyngeal sphincter -After entry into the esophagus, food is forced down it by involuntary peristaltic waves in stomach; complete swallowing process takes an average of about 5 -10 seconds -If respiratory passages are not isolated properly, other motor responses usually initiate gag reflex, which propels food up & out; this reflex is often weak or absent in patients w/dysphagia Difference between age groups -Infants: swallowing process is constantly changing neuromuscular process; most fetuses can swallow by about 15 weeks of developement -At birth, infants usually have developed a sucking reflex, which initiates swallowing for about 1st 7 months of life; they have relatively small oral cavity & highly positioned larynx, leading to a pattern of inhalation, swallowing & then exhalation; tongue often raises & lowers or protrudes; as oral cavity enlarges, these actions usually subside by about 9 months of age -In children, ability to feed themselves independently must be learned & employs many motor skills -Children w/ neurological impairments often find self-feeding difficult, especially if they have been tube-fed for a long period or have issues r/t posture or lip/mouth control -Older adults: tongue loses motor function & strength making swallowing slower & weaker, particularly in people over age 60

Urinary Incontinence card #2

Postvoid Residual (PVR) -Measurement of difference between amount of urine voided & residual bladder volume -A good diagnostic test for adequacy of bladder voiding; usually taken w/ bladder scanner; pt voids into measurement device while breathing deeply & contracting pelvic muscles; urine volume documented; then lies down & either a bladder scan or sterile catheterization is performed to verify residual volume, which is recorded -Total volume is sum of voided volume + residual volume after voiding (PVR); ranges are <50ml for adequate & 100-200ml for inadequate voiding Diagnostic Tests for Initial Evaluation -Urinalysis or lab urine analysis should be done; these tests look for blood (infection, malignancy, or urinary stones), glucose or protein (DM), or pus/bacteria (infection) -Kidney function & DM sign of polyuria are evaluated by blood tests for BUN, creatinine, glucose, & calcium levels -Imaging: US or IV pyelogram of upper and/or lower urinary tract are performed, especially w/ neurogenic bladder dysfunction ID of Urinary Incontinence Mechanism -Urodynamics: assessment of anatomical & functional condition of bladder; employs several techniques to distinguish between urge, stress, & overflow incontinence -Other dx procedures: cystometrogram (CMG), electromyogram (EMG), urethral pressure profilometry (UPP), uroflowmetry or videourodynamics, & cystourethroscopy -CMG used to eval detrusor muscle function utilizing urethral catheter to fill bladder to capacity or until contraction; used to look at filling or voiding -EMG: touches electrode or wire to urethral sphincter to eval innervation -UPP: looks at pressures within urethra -Cystourethroscopy: uses endoscope to ID lesions or constricted areas in urinary tract Causes of Urge, Stress, & Overflow Incontinence -Urge: loss w/strong urge to void, can be caused by instability of detrusor muscle or bladder in general, hyperactivity of detrusor in conjunction/ impaired contractility (elderly usually), or increased involuntary movement of detrusor or lack of synergy w/ its sphincter; latter can d/t CVA; CMG (w/ or w/o EMG) is dx test of choice -Stress: loss during activities such as coughing, laughing, or bending, can be d/t lesions of intrinsic or neurogenic sphincters or detachment & mobility of bladder neck (women) --Associated w/lack of detrusor contraction & abdominal pressure & is generally diagnosed by stress tests, CMG, UPP, videourodynamics -Overflow: dripping associated w/ overdistended bladder, can be d/t lack of detrusor contraction (neurogenic in nature) or obstruction at urine outlet (r/t disease or surgery)

Language card #5

Pragmatics -Study of language in actual use beyond just words & grammar; while most language is controlled by L cerebral hemisphere, R hemisphere contributes to components of pragmatics & these can be impaired if there is damage to that side; these components include prosody, kinesics, & facial recognition & expression -Prosody (or prosodia): rhythm of speech that conveys nuances of meaning, attitudes, & emotions; it includes things such as intonation, pauses, accents, emphases, & melody -Kinesics: study of communication using body language, in particular gestures or movements that accentuate or enhance verbal communication; pantomime is variation using only gestures; both brain hemispheres seem to be involved in understanding & use of gestures & pantomime, but specifics are unclear at present; facial recognition & expression also contribute to pragmatics by communicating emotions & mood Motor, Sensory, & Global Aprosodias -Aprosodias: deficits in expression or comprehension of nuances of meaning in verbal communication; motor aprosodia characterized by intact comprehension of both prosody & gesturing, but poor expression thereof, resulting in flat, monotone speaking patterns accompanied by L sided hemiplegia & sensory deficits; usually caused by R frontal or anteroinferior parietal brain damage -Sensory aprosodia: characterized by poor understanding of prosody & gestures but intact ability to use these features in expression; main defect is R-sided posterotemporal or posteroinferior parietal damage; other senses such as position & vibration may be affected -Global aprosodia: prosodic & kinesic expression & comprehension all diminished; caused by large lesion affecting several R lobes & possibly hemorrhaging; they may also have L side hemiplegia, visual defects, & other sensory loss

Pharmaceutics

Preparation & dispensation of drugs or meds

Pressure Ulcers card #5

Pressure-Relieving & Pressure Reducing Support Surfaces -Both types of surfaces designed to interface w/ skin at a pressure close to capillary closing pressure to ensure proper blood flow; interface pressures are slightly different, w/pressure-relieving surfaces keeping boundary pressure below 32mmHg & pressure reducing surface maintaining it above 32 mmHg yet lower then conventional mattress -Support surfaces: can be static, distributing body weight over sizeable area, or dynamic, using electric power to inflate/deflate certain areas of device to reduce pressure when needed; completely framed specialty beds that reduce pressure (best choice) are available, but overlays are placed on top of regular mattress or a mattress replacement w/o special framing is used -Upscale specialty beds use electric pumps to control pressure; 3 types-low air-loss using pillows filled w/ air, high air-loss or fluid-air using stream of air through silicon beads, & kinetic therapy using constant motion or oscillation; also types of surfaces to relieve pressure to heel area Local Wound Care -Agency for Health Care Policy & Research developed flow chart for tx of PUs; suggests initial ulcer debridement or affected tissue removal by selective methods like surgical removal w/ scalpel or autolytic or enzymatic debridement; non-selective methods such as dressings, irrigation, or whirlpool can be used instead -Wound should be cleaned w/ NS solution using enough pressure to cleanse but not inflict trauma; exudate should be absorbed & sinus tracts closed off; some protocols suggest cleansing followed by debridement; antiseptic cleansers should not be used -Issue of possible infection should be addressed further using topical antiseptics or antibiotics, treatments such as hyperbaric O2 or electrical stimulation, & possibly systemic antibiotics targeting likely infectious agents -Next, wound dressings that will keep area moist are applied; later management depends on course of healing & may include surgical intervention; possible wound complications include osteomyelitis

HIV card #3

Prevention -No cure, preventative measures are crucial -Primary: reduction of risk for HIV transmission through education about cessation (or safer) drug use, promotion of monogamy, info about safe sex practices (condom use) & avoidance of contact w/blood & bodily fluids -Secondary: early screening & diagnostic procedures before body is severely immunocompromised to slow down progression & prevent further transmission -Tertiary: implement meds, disease control, & lifestyle changes to reduce severity of disability Antiretroviral medications -3 main classes -2 inhibit reverse transcriptase enzyme, nucleoside reverse transcriptase inhibitors (NRTIs), & non-nucleoside reverse transcriptase inhibitors (NNRTIs) -HIV (RNA virus) utilizes enzyme called reverse transcriptase to convert RNA to DNA, which is incorporated into cellular CD4+ DNA for further replication -NRTIs (zidovudine-Retrovir, AZT) incorprate w/ viral DNA, making HIV unable to replicate -NNRTIs (nevirapine-VIRAMUNE) bind directly to reverse transcriptase & thwart conversion of RNA to DNA -Protease inhibitors (ritonavir (Norvir) prevents HIV assemblage in & release from CD4+ cell -NRTIs & protease inhibitors negatively impact lipid parameters Desired outcomes -As r/t immune status & opportunistic infections: relatively high CD4+ cell count, no opportunistic infections, imperceptible viral load, symptomatic improvement, enhanced nutrition & weight gain, enough endurance to perform ADLs, & control of pain & cognitive deficits -Adherence to medication schedule, hope, & acceptance of health status indicate psychosocial improvement -Psychosocial issues can vary by age & stage of disease -Nursing outcomes should address process of providing services & periodic evaluation in order to improve care -During terminal stages of AIDs, nurse's responsibility to help in decision-making about care options such as hospice care

Hand appearance in rheumatoid arthritis (RA) and osteoarthritis (OA)

RA: Subcutaneous nodules or protuberances on top of hand near joints, also has ulnar drift or bowing of fingers toward the outside and the ulnar bone OA: May have Bourchard's nodes and/or Heberden's nodes which are swollen areas above joints in center or near the nail of each digit respectively Morning stiffness experienced in both RA & OA, lasts longer & shows less improvement with RA

Brain Injuries card #5

Rancho Los Amigos Levels of Cognitive Function Scale (test question) -Assesses functional responses after brain injury; full scale has 10 levels but actually only first 8 are used since levels IX & X r/t advanced cognitive skills; levels are as follows: --Level I: no response, no acknowledgement of pain, touch, sound, or sight --Level II: generalized reflex response, unpredictable non-specific response --Level III: localized response, can blink or move in response to sounds or pain but unpredictable actions upon command --Level IV: confused-agitated, alert but agitated w/ undirected activities & low attention span --Level V: confused-nonagitated, aware of immediate environment but easily distracted * unable to focus on new tasks --Level VI: confused-appropriate, awareness of time & place distorted w/ some prior but not good recent memory recall, can follow easy directions --Level VII: automatic-appropriate, able to cope well in familiar but not strange surroundings in a mechanical fashion, can't problem solve --Level VIII: purposeful-appropriate, more self-aware & able to learn new tasks & deal w/ unfamiliar situations Agitated Behavior Scale (ABS) -Tool for behavioral management; rates 14 different possible behavioral excesses that can impair day-to-day functioning & impede tx; each behavior is given a numerical value of 1 (absent), 2 (present to slight degree), 3 (present to a moderate degree), or 4 (found in a extreme fashion) -Types of behavior rated: attention span, patient, cooperativeness, presence of violent actions, volatile anger, self-stimualtory activities, grasping of needed equipment, straying outside tx area, too much movement, repetitive actions, talking excessively or loudly, abrupt mood changes, spontaneous crying or laughter, & verbal or physical abuse of self -All scores added for a total score or they may be grouped into behavior that is aggressive, labile, or indicates lack of inhibition; ABS can be used to look at changes that may be dependent on time of day or that change over course of recovery

Spinal Cord Injuries (SCIs) card #3

Respiratory Function Goals -Capacity is affected by muscles stimulated by range of spinal cord nerves at levels C2- T12; if injury is at C4 or above, mechanical ventilation is usually necessary d/t resp. paralysis; lower level SCIs generally require hard-hitting pulmonary management as well initially, but goal is later removal of ventilator -Complications such as pneumonia or respiratory failure can occur; interventions: deep breathing exercises, drugs to control secretions, suctioning devices or chest physiotherapy-all may be needed to establish goal of clear airway; ultimately, pt needs to be taught exercises for lung expansion & good pulmonary grooming Changes During Spinal Shock -Occurs initially d/t spinal shock from shutdown of sympathetic nervous system; during this period, may experience changes in thermoregulation & orthostasis, cardiac arrhythmias, thrombophlebitis, or autonomic-dysreflexia; ability of hypothalamus to regulate core body temperature can be affected, resulting in a temperature closer to external environment, which may be mistaken for infection or other problem -Many develop orthostatic hypotension or light-headedness when adjusting from a prone to upright position d/t lessened sympathetic response & blood pooling in LEs; there pt's BP need to be monitored & their abdomen may be wrapped to establish tissue perfusion; may experience bradycardia; these changes most common w/ injuries at T6 level or above -DVT or PE can occur, indicating interventions such as TEDs or SEDs; when spinal shock is over, potentially grave phenomenon autonomic dysreflexia or rapid increase in BP can occur Goals for Urinary & Bowel Elimination Function -During spinal shock & afterwards, SCI pt may have altered bladder &/or bowel function; goal for urinary elimination is establishment of containment system, usually indwelling, self-intermittent, or external catheter w/ drainage system; during acute rehab, routine is established & long term the pt is taught how to self-manage the system -Main bowel elimination goal during spinal shock is establishment & maintenance of clean bowel; those w/ UMN damage are prone to develop a reflex bowel when shock resolves; Pt's w/ LMN damage lose motor tone & develop a limp rectal sphincter; acute rehab period, daily bowel program (includes hydration & dietary changes) needs to be started & continued later at home to prevent incontinence; UMN-given suppositories to encourage reflex emptying while LMN-meds for motility

HIV/AIDS treatment

Reverse transcriptase (RT) inhibitors: Ziagen, Epivir, Ziagen, Viramune, Rescriptor, Sustiva Protease inhibitors: Invirase, Norvir, Viracept Fusion inhibitor: Fuzeon (prevent virus from replicating)

Hip Replacement

Routinely done on people with various types of arthritis, hip fractures, bone tumors, and other musculoskeletal disorders Hemiarthroplasty-replacement of femoral head THR-replacement of femoral head & acetabular cup

Urinary Incontinence Treatment card #1

Scheduled Voiding Regimens -5 types that can be established to aid incontinent patients w/ stress, urge, mixed, & uninhibited neurological bladder dysfunction -Timed voiding: teaches to void on fixed scheduled q 2 hours -Habit training: set voiding pattern established based on historical data about toileting habits -Patterned urge response: often used in elderly, electronic monitoring device gauges periods of incontinence -Prompted voiding: incorporates rewards such as praise or assistance for remaining continent; primarily utilized in institutional or caregiver-assisted homebound situations -Urinary bladder training/retraining: after continence has been established Bladder Retraining -Used after establishment of continence to enhance voiding pattern, re-establish regular bladder function, & educate on how to control urination -Used for patients w/ hx of urge, stress, or mixed incontinence; used w/ relatively cognitive & motivated patients w/ uninhibited neurological bladder dysfunction -Patient instructed to eliminate or curtail use of caffeine & aspartame, drink 6-8 glasses daily of other liquids, & stop drinking several hours before HS if they have night problems -Taught relaxation techniques that alleviate urge sensation, preferably during bedside cystometrogram-breathe slow & deep until urge subsides -Using historical data about voiding pattern, period between voiding is increased in 15-minute increments; instructed not to void without experiencing urge, not to rush to facilities, & to use relaxation techniques in trigger situations -Patient should keep bladder records at home & schedule follow-up visits w/nurse Kegel Exercises -Pelvic muscle exercises that involve conscious contraction of pubococcygeal muscle in order to enhance urethral resistance & pelvic musculature & diminish incontinence -1st taught how to find pelvic muscle by either stopping urine flow or in females by pulling vagina, rectum, & urethra forward -Muscles are exercised by alternating voluntary contractions & relaxation periods of 10 counts each -Should be done TID for 10 minutes each session; can be done in just about any position-supine or seated positions are preferred; should be cautioned about activating other muscles (stomach) while doing Kegel exercises

Models of Movement

Sensorimotor -Classic movement theories regard motor development as a compilation of developmental milestones reached through maturation directed by CNS; life span viewpoints envision motor behaviors as changeable during life as a result of internal as well as external factors; models of movement use both principles -Feldenkrais method: sensorimotor approach because it touts reestablishment of lost or changed functional capacity through education & adaptation -Bobath program: patient actively participates in goal-oriented tasks to improve movement through postural & other changes that enhance sensations & mobility -Proprioceptive neuromuscular facilitation approach (PNF): another example emphasizing movements of extremities Dynamic Systems -View movement as a non-linear process in which many parts are interconnected in multifaceted & dynamic manner; any rehab measures that emphasize tasks to engage use of extremities that have been affected in order to relearn movements are dynamic systems -Variant is dynamic pattern theory (DPT): patient is aided by nurse in reestablishment of some measure of function to perform ADLs; accomplished through interventions that make it easier for patient to perform these activities; also many behavioral tactics that can reduce stress or obliterate pain such as biofeedback & massage

Pressure Ulcers card #4

Skin Care & Early Treatment of PUs -AHA recommends daily inspection & documentation of skin of people at high risk for skin damage; skin should be cleansed gently w/ mild agent & water that is not too hot at time of sullying & at regular periods; skin care measures to decrease risk of PUs: avoiding dry skin through use of moisturizers, maintaining humidity levels above 40%, avoiding contact w/ cold, managing sources of moisture such as wound drainage, sweating or incontinence, & minimizing sources of possible skin injury by avoiding massage in bony areas & employing correct positioning & moving techniques to avoid friction & shear -AHA advocates use of protective films, dressings, paddings, & lubricants to minimize friction; also suggests nutritional support Management of Mechanical Loading & Support Surfaces -AHA recommends that those at risk for developing PUs be moved at least Q 2 hours if bedridden; those in w/c should shift weight Q 15 minutes; measures to reduce ulcers in bedridden patients include positioning devices such as pillows or wedges under bony protrusions & use of mattresses designed to reduce pressure (made of foam, gel, or containing water) -AHA also suggests use of pressure -reducing supports & cushions (not donut shaped) in w/c; keep HOB at lowest elevation possible; use support such as trapeze or bed sheet to move patient instead of pulling on patient

Holism & Spirituality card #2

Spiritual Assessment -Generally done after trust & rapport have been established, spiritual histories should go beyond questions about religious practices & beliefs, they should also incorporate queries about person's support system, notions about God or a deity, & how illness has impacted spiritual beliefs -There are several Likert scales (measuring agreement/disagreement w/statements) for spiritual assessment; these include Spiritual Well-Being Scale (SWBS) & the Spiritual Assessment Scale (SAS); one of the best scales that minimize cultural bias is Spiritual Involvement & Beliefs Scale (SIBS) which has pt evaluate 34 statements on a scale from strongly disagree (1) to strongly agree (7); also looks at frequency of 5 types of behaviors that reflect spirituality Diagnoses, Interventions, & Desired Outcomes -5 possible nursing diagnoses r/t pt's spirituality, patient may have difficulty making decisions, goal is to establish ability to process information & make decisions that can be facilitated by nurse though goal setting & use of various techniques such as meditation or relaxation -Another potential dx is dysfunctional grieving, here acceptance & grief resolution is a desired outcome, which can be aided by working through the grief & guilt -Hopelessness is a common spirituality-related classification, in order to restore hope & coping ability, nurse should use measures that instill hope & stabilize patient's mood; some pt's can be categorized as at risk for spiritual distress, particularly when they are nearing the end of life; in this care, nurse should employ all means of spiritual support to aid person in accepting their health-related situation -Readiness for enhanced spiritual well-being, which means nurse should use any methods to enhance pt's spiritual or religious beliefs, develop pt's self-esteem & help patient to cope

Sleep card #1

Stages -Individual undergoes 5-6 cycles of pattern of slumber; each is divided into 5 stages; 1st 4 stages are associated by REM sleep -Stage 1: relatively short, eyes movements shift slowly from side to side & blinking diminishes -Stage 2: half of sleeping period, somewhat deeper sleep w/ not much NREM -Stages 3 & 4: together compromise about 20-25% of sleeping time, are both sleep w/ slow eye movement but wave pattern of each is different -Stage 5: REM sleep, which is period where people experience dreams; about as long as stages 3 & 4 combined -Each stage has characteristic wave patterns on polysomnography (procedure combining electroencephalogram, electrooculogram, & electromyogram techniques) Physiology -Sleep center is situated in portion of midbrain called midline raphe system (controls noradrenergic & cholinergic responses); in course of NREM sleep, secretion of various hormones is either enhanced (growth & luteinizing hormones) or suppressed (adrenocorticotropic & thyroid-stimulating hormones) -By deep sleep in stages 3 & 4, vital functions such as BP & respiration are minimized while CV tone is augmented; homeostatic mechanisms initiated during sleep are designed to gradually take person through following stages in sequence: wakefulness, deep sleep, REM sleep, & again wakefulness -Sleep restores vigor; if normal patterns are disrupted through unhealthy habits or use of some medications, this restoration can't occur properly; sleep-wake cycles are also affected by an individual's circadian or daily rhythm

Sexual Response

Stages -Sexual response depends on intricate interplay of physiology, neurotransmitters, & psychological factors; there are 5 phases of complete sexual response --1. Desire: a strong craving for a sexual experience, primarily psychological in nature --2. Arousal: stimulation of sexual desire as evidenced by physiological changes including increased pulse & BP, filling of blood vessels in genital areas, nipple stiffness, erect penis, & vaginal lubrication --3. Plateau: further elevation of pulse, BP, & respiratory rate in anticipation of next stage, orgasm --4. Orgasm: peak of respiratory & HR, muscle spasms in bursts (women), ejaculation of sperm (men) --5. Resolution: relaxation & reversion to normal physiological levels before excitement Neurological Pathways to Erections -Normal, neurologically intact man can achieve erection through either of 2 pathways -1st: Reflexogenic-continual touching in genial area is communicated through pudendal nerve to sacral spinal cord (S2-S4); parasympathetic efferent nerve impulses are then transmitted via pelvic & cavernosal nerves to relax smooth muscle in penis & cause erection -2nd: Psychogenic-no tactile stimulation is necessary, only mental impressions or evocation through other senses such as taste or smell; route is thoracolumbar sympathetic nerves (T10-L2) directly to sexual organ; SNS also involved in ejaculation, later reduction in swelling & tone through control from hypogastric nerves Neurological Foundation of Female Sexual Response -Clitoris & vagina also are innervated by pudendal nerves, which when stimulated signal sacral plexus (S2-S4); also have pelvic nerves present in vagina, clitoris, & more internal fallopian tubes that receive parasympathetic signals from hypogastric & uterine areas, causing enlargement of clitoris & vaginal secretions -Responses can also be psychogenic as w/ male erection; connection of muscles in pelvic floor & vaginal wall is d/t activation of somatic pudenda nerves while sympathetic responses in ovarian & uterine regions are more controlled by thoracic & lumbar regions of spinal cord -In both sexes, maintenance of arousal is also influenced by brainstem, particularly hypothalamic-pituitary axis where production of sexual hormones is controlled

Pressure Ulcers card #3

Stages of Healing -Vascular response starts (platelets recruited, capillaries dilate, & fibrin network develops) -Initial stage is inflammatory, usually last up to 6 days, involving neutrophils, macrophages, mediators, & WBCs; distinguished by swelling, redness, blood in area, & pain -Proliferative stage: several weeks in length; wound bed filled w/ granulation (red, shiny, granular) tissue; collagen generated for strength; angiogenesis occurs; & wound contracts in size -Maturation stage: new epithelium formation to close up wound, scar tissue, remodeling of wound, & greater tensile strength -Acute wounds that are closed faster (deliberate closure after surgical incision) generally who not have as much scarring while PUs (considered chronic wounds) or tertiary wounds whose closure has been intentionally delayed will have more separation, scarring, or infections that must subside before complete healing Bates-Jensen Pressure Sore Status Tool -An adjunct to rate wound healing; 13 different items at wound site are each rated on scale from 1-5 (increasingly more severe) on several dates -Progress assessed by adding up all scores on one date & plotting total score over time to see if it decreases; parameters include size, depth, distinctness of edges, & amount of ulcer undermining; both necrotic tissue & exudate assigned scores r/t type as well as amount -Skin color within 4 cm of surrounding tissue is evaluated with respect to ethnicity; within same area, amount of peripheral tissue edema & induration are measured; amount of epithelialization or epithelial resurfacing & covering of wound is calculated; 65 points possible, with cutoff of 13 points or 1 point for each area considered wound regeneration

Skin card #1

Structure -Outer layer is epidermis, serves as line of defense between skin & external forces & to maintain skin integrity; subdivided into 5 strata or layers, which starting from outermost going inward are stratum corneum, lucidum, granulosum, spinosum, & germinativum -Below strata of epidermis is dermis; located here are sebaceous & sweat glands, blood vessels, hair roots, & nerve endings; made up of a tough fibrous connective network that provides a foundation for epidermis, skin tone through collagen production, & elastic recoil via presence of elastin -Below dermis is subcutaneous tissue made up of more connective tissue plus fat; larger blood vessels, nerves, & lymphatics are present Functions -All skin layers serve protective functions; parts of outer epidermis (nails & hair) contain fibrous protein keratin, which forms barrier to injury; epidermal layer also hinder growth of microorganisms & make skin strong through intracellular interactions -Dermis: contains fibroblast that aid wound healing & lymphatic & blood vessels that enhance anti-inflammatory & anti-microbial responses; also provides mechanical strength d/t containing collagen, elastin, & a ground substance -Subcutaneous: acts as shock absorber -All layers aid in temperature regulation; eccrine sweat glands controlling evaporation are in epidermis; cutaneous vasculature, which monitors heat conduction, is present in dermis; subcutaneous fat cells perform as insulation -All layers have various sensory receptors as well; in addition, epidermis performs some unique functions; its relative impermeability aids in maintenance of water balance or homeostasis & plays a role in vitamin synthesis as well

Pharmacodynamics

Study of mechanisms of action of a drug & end result of its use on body

Communication Disorders card #2

Supportive Behaviors for Rehab Team -Nurse, rehab team, & family need to be constantly supportive w/ praise, honesty, & real concern for pt while at the same time allowing them to be as independent as possible; all these people need to acknowledge pt's frustration & not impose unrealistic demands on them; important to see even negative behaviors as communication attempts -Therapy addressing speech or language problems should be delayed until pt is psychologically prepared; if pt can understand & has intact cognition, they should be treated appropriately, not talked down to -For patients w/ impaired comprehension, emphasis should be on communicating slowly, including pt in discussions when in their presence & accepting pt's abnormal speech patterns in a non-critical way; team members should always speak to pt in calm, reassuring, & direct manner Ways to Facilitate Communication -Generally tailored to individual & type of deficit involved & there are some general guidelines -Communications w/ pt should be spontaneous, topical, frequent, & relatively brief; gestures & other aids should be incorporated if needed & they should be given sufficient time to respond; there are many tactics for patients whose ability to comprehend is intact, such as cueing, having pt describe what nurse is doing, expanding on statements pt has made, & encouraging pt to verbalize in any manner they wish -Should be allowed to make mistake & only be interrupted if they become very perturbed; people w/ aphasia or aprosodia have difficulty understanding as well, which means further measures are necessary; their environment must be quiet in order to communicate & one must secure their attention 1st -Other people need to speak to them slowly, clearly, & directly incorporating gestures & reinforcing their responses when correct; generally, comprehension is addresses before language production

Gerontological rehabilitation card #2

Susceptibility to falls -7 out of 10 inadvertent deaths in older adults at least 75 are associated with falls -Many chronic illnesses increase fall susceptibility -Only small proportion of fall caused hip fractures regain ADL functionality -Conditions r/t falls: neurological diseases, CVA, MS disorders & muscle weakness, sensory problems (balance or sight), CV abnormalities; GU issues (incontinence); Resp: low blood oxygenation or pneumonia -Much increased fall risk is r/t med usage (narcotics, diuretics, antidepressants) or psychological factores such as confusion or anxiety -Restrictive clothing & improper use of w/c or walkers also increase risk of falls Screening for balance & gait function -Timed Up & Go test (assesses balance & gait): seated in armed chair, get up without use of arms, stand still briefly, walk 0.75 feet, turn, and go back to sit in chair; nothing should be touched including chair arms-if unsteady or must use support, further evaluation is indicated -Berg Balance Scale: addresses 14 items r/t balance -Ataxia (lack of muscle control): test by having patient perform 2 sequences, finger-to-finger & heel-to-shin Decreasing risk for falls -If new admit or recently moved, orient to new environment & make patient friendly -If known to have hx of falls or physical weakness, need to use tools such as BSC, bed alarm devices, and antislip mats; watch during ambulation -If postural hypotension, use TEDs and 1.5 liters of hydration daily -If is or could be incontinent, regular voiding & easy BR access are indicated -Assess & monitor drug use, including pain meds -If visual impairments, lighting must be adequate, unobstructed environment, & glasses usable -Altered Mental Status (AMS) patients need relaxing environments & close supervision -Those with emotional or other psychosocial problems should be assessed by professional

Postpolio syndrome (PPS)

Symptoms; tiredness, low energy, lack of concentration, joint/muscle pain, muscle degeneration, cognitive defects; appear several decades after original polio infection Tx: energy conservation techniques, weight loss, use of braces

Developmental disabilities (DD)

System of services -Federal level: DD Act overseen by US Admin on DD (ADD) -State level: Most services are programs within school or child welfare system or early interventional plans -Adult forms of assistance: supervised group homes, adult foster care, or more independent choices (supported living); yearly plan is set up by team of caregivers & medical personnel to address needs -State agencies often offer employment services Relevant issues -People with DD often get inadequate health care d/t service inaccessibility or behavioral & learning problems that alienate health care workers -Health care consent is sometimes difficult because DD pt is considered competent -Often sexually abused, may be unable to verbalized abuse -When DD adolescents get ready to leave educational system, they get a customized "transition plan" (Individualized Education Plan) around age 16; may allow continued vocational & other training until age 21 -Still, unemployment rate is high -As they age, disorder-specific or med-related health problems plus normal gaining issues -Often DD pts place hardships on family with childhood, transition periods, & aging

Brain Injuries card #6

Tools to Assess Brain Injuries -Galveston Orientation & Amnesia Test (GOAT) often utilized to assess patient's cognitive & orientation abilities to see whether they emerged from post-traumatic amnesia period; is fast observation that looks at 10 components & assigns a total score ranging from 1-100 w/ cutoff of 75; administered on consecutive days, indicating PTA clearing -Similar scales: Disability Rating Scale (DRS), Neurobehavioral Rating Scale (NRS), & Overt Aggression Scale-Modified for Neurorehabiliation (OAS-MNR); Katz & Alexander have described 6 stages of recovery from diffuse axonal injury as well; according to their classification, these stages progress through coma, a vegetative state, a condition of minimal consciousness, a confusional state during PTA, increasing independence after PTA resolves, & finally restoration of social abilities & re-entry into community Anoxic Brain Injury (ABI) -Any brain damage that results from inadequate blood flow & oxygen perfusion into area; often occurs after cardiac arrest, choking, drug overdosing, near drowning, during surgery, or after a traumatic injury; person can develop speech or movement problems & loss of recognition; mild cases typically characterized by amnesia, lack of attention, poor balance & agitation -With severe anoxic brain injuries, individual can also develop seizures, spasticity, & language problems; in most severe cases, patient can able to communicate reliably & responds inconsistently to environment; patients generally are not completely comatose & can open eyes

Language card #6

Transcortical & Other Aprosodias -3 types of possible Transcortical aprosodias: motor, sensory, & mixed -Motor: spontaneous affective prosody & gesturing are both compromised as well as some prosodic comprehension; comprehension of nuances & gestures is affected in Transcortical sensory aprosodia, whereas both expression & comprehension of features are absent in mixed condition -Ability to express prosodic repetition is retained in all of these; areas of damage in transcortical aprosodias have been postulated but not proven -Other possible aprosodias are conduction type, where only defect is poor affective prosodic repetition & anomic aprosodia mainly characterized by inability to understand gestures

ROM

Types & Evaluation -The amount of movement possible in joint; can involve flexion (bending) or extension (straightening); foot flexion measured as plantar flexion, the downward motion of foot at ankle joint, or dorsiflexion, upward motion at same point -Can be described as motion occurring away from midline, toward midline, or circular (abduction, adduction, & circumduction respectively) -Rotation around a joint can occur internally or externally; pronation or supination describes the amount of turn in elbow relative to hand orientation -Can be measured actively as when the patient moves their own muscle, or passively, as when nurse moves a limb to facilitate full ROM -Functional ROM refers to ability to perform ADLs requiring a full ROM Assessment of Upper & Lower Extremities -UE ROM exercises should include evaluation of shoulder for its capacity for flexion & extension measured by how far patient can lift their arm or flatten it on bed respectively -Shoulder abduction & adduction are measured by moving supported arm either away from or toward body; external & internal rotational shoulder capabilities are assessed by keeping elbow at right angle against bed & lifting or pressing down on arm -Elbow flexion & extension measured by bending & straightening elbow; pronation & supination of forearm are tested by turning palm in all directions; joints @ wrist, fingers, & thumb are checked for movement in all directions, including thumb opposition -For LEs, hip is tested for ROM r/t flexion, extension, strength (ability to hold leg up 5 seconds), abduction, adduction, & rotational ability both internally & externally -Knee flexion & extension are tested w/ hips flexed at right angle; heel cord is stretched back for a count of 5; toes are flexed & extended, & foot flexion is also assessed

Intervention for Urinary Retention

Urinary retention d/t spinal cord damage, enlarged prostate, or neurogenic bladder dysfunction -Immediate goal: safely void bladder -Primary intervention: urinary catheterization, either as indwelling device inserted within urethra or an artificial surgically created opening in pubic area (both provide constant draining) --Can be intermittent: catheter is inserted & removed at regular intervals, usually to maintain manageable volumes -Hospital setting: sterile technique strongly recommended during insertion & removal in order to thwart catheter-associated UTIs -Home setting: clean technique should be used; small bore catheters, irrigation methods, topical ointments, & avoidance of unnecessary catheter changes

Holism & Spirituality card #3

Value of Other Nursing Interventions -Instillation of hope or optimism actively enhances coping mechanisms while a feeling of hopelessness or lack of control impedes them, hope is entrenched in perception; also can have 2 components, a horizontal one focused on worldly relationships & a vertical one r/t eternal goals & connections; latter one can still provide optimism when earthly actions have failed -Humor & laughter are effective tools for diffusing tension & grief momentarily; nurse can facilitate spiritual growth & support pt in their beliefs by taking them to services or providing educational material -Also several types of therapy that have been found to be useful, such as use of music or other arts, bibliotherapy (reading), or reminiscence therapy in which various strategies are used to involve previous pleasant memories

Eye & Vision card #2

Vision Assessment -1st step is a history-considered to be visually impaired if they indicate that they are blind in one or both eyes; most common visual acuity test is Snellen reading test: pt stands 20 feet away from an eye chart & glasses may be worn if needed, each eye is tested separately & rated as 20/x with x being number of feet away a person w/ normal vision can read what is pt can see at 20 feet -Visual fields should also be checked by bracing head & having them follow movement of pen; restricted eye movement may indicate visual lesions-eyelids, conjunctiva, sclera, & pupil are visually inspected to look for evidence of inflammation, underlying medical problems -Size & shape of pupil is examined (should be 3-5mm); pupillary reaction is tested by moving a penlight across visual field from a distance & assessing whether the pupils converge & constrict symmetrically in response; lacrimal sacs & eyelids are examined to look for obstructions & inflammation Vision Disturbances -Many visual disturbances that are not blindness -Most widespread type of visual impairment is refractive error (blurriness d/t lack of precise retinal focus); completely treatable using corrective lenses; there are several types of intraocular diseases, notably cataracts, glaucoma, & retinal detachment; cataracts are eye disease in which lens becomes covered w/ opaque film that impedes passage of light & causes blurriness, image distortion, & problems perceiving colors; tx is cataract removal -Glaucoma: generally imperceptible high pressure within eyeball that can eventually damage optic nerve & cause vision loss if untreated; is treated w/ timolol or pilocarpine drops or surgery; serious variant is closed-angle glaucoma in which replacement of iris occurs, pressure shoots up rapidly & there is acute pain; with retinal detachment, rods & cones deteriorate & surgical vitrectomy is generally done Hemianopsia -Blindness affecting half of visual field in one or both eyes after brain injuries or other impairments; there are 3 types --1st: most common type-homonymous in which vision is lost in different visual fields of each eye; for example, temporal part affecting peripheral vision is lost in one eye & the nasal field which is more centrally located is lost in the other -2nd: bitemporal in which peripheral vision in both eyes is affected -3rd: attitudinal, person can have anopsia or blindness in one eye or have vision loss in one area of a single eye, such as R nasal hemianopsia, which is visual impairment affecting only the nasal or overlap field

Language card #3

Wernicke's Aphasia & Transcortical Sensory Aphasia -Wernicke's aphasia can result from brain damage to Wernicke's area; here major defects is verbal comprehension; reading, writing, repetitive, & naming functions are impaired as well; however, they are able to speak w/ease, inflect properly, & use proper syntax; however, they use incorrect words, nonsense words or phrases, & make phonetic substitutions -They may also have other sensory deficits such as loss of visual fields; these deficits make communication w/ individual difficult, & people in contact w/ affected patient (including nurse) must rely on gesturing & using facial changes to communicate -Transcortical sensory aphasia can imitate Wernicke's aphasia except that repetition is functional & area of damage is on border zone of parietotemporal intersection Global Aphasia & Mixed Transcortical Aphasia -Global (or total) aphasia is marked incapacity to comprehend verbal or written language or to write; all language abilities including speech are impaired except possibly naming, & person has loss of use of R side as well as visual field & sensory deficits; caused by injury to massive regions in frontal & parietotemporal language parts of brain -Mixed Transcortical aphasia can resemble global aphasia except that person has intact repetition abilities, this type of aphasia is usually caused by O2 deprivation or head injury to cortical areas around but not directly within language centers; these individuals only repeat what they have heard & do not speak otherwise

Pressure Ulcers card #6

Wound Dressings -For less severe stage I & II wounds, use transparent film dressings-they are clear sticky dressings made of polymers that are impermeable to water but allow flow of O2 & water vapor -Stage II wounds often treated w/ another type of dressing called hypercolloid-contain gel-forming products attached to a film or foam matrix & create an adhesive waterproof absorbent layer -Many dressings for stage III & IV wounds, all of which adsorb to some degree; one variety is the biodegradable alginate dressing (made from seaweed); another is gauze (most porous, often combined w/ gels or other compounds) -Hydrogel dressing-made of non-sticking, water-soluble gel; advantage is that is absorptive w/o introducing moisture; also form dressings that often saturated with other compounds Unconventional Treatment -Include use of growth factors & systemic administration of anabolic steroids; one fairly common tool is electrical stimulation of area, which theoretically boosts body's bioelectrical scheme & associated cellular processes -Application of continuous negative pressure to decrease swelling & kill bacteria at site & facilitate angiogenesis, a variant is vacuum-assisted closure (VAC) during surgery; hyperbaric O2 therapy, in which whole body is subjected to a series of high-pressure O2 treatments in a chamber, is used for a variety of disease states, including wounds --Rationale: increased O2 concentration in bloodstream & tissues will prompt wound-healing components of angiogenesis & collagen production -Pulsed lavage: wound is cleaned w/ NS delivered in pulses electronically is fairly common, more controversial is high-pressure versions

Barthel Index (BI)

functional assessment that rates 10 functions, each on 3 point scale (independent, requires assist, or completely dependent)