Concepts II - Mobility

Immoblization

*Hold the appendage in place so that healing can occur *Bone remodeling takes several weeks before the fracture is stable *Protect the bone from further injury *Cast, splints, abductor pillows, shoulder restraints, braces, and traction *Assistive devices - devices for ambulation - ADL's - canes, walkers, wheelchairs, and prostheses *Patient handling technology - transfer mats, slings, and lifts.

Drugs used to treat Head and Spinal Cord Injuries

*Methylprednisolone (Solu-Medrol) -Decreases inflammation by suppression of leukocyte migration to injury site; decreases capillary permeability *Baclofen (Lioresal) - Inhibits synaptic responses in CNS by decreasing GABA, thereby decreasing frequency and severity of muscle spasms *Dopamine (Intropin) - Acts on alpha receptors, causing vasoconstriction in blood vessels, thereby raising blood pressure

When an accident victim complains of neck or back pain, or cannot move the legs or has no feeling in them, treat the victim as if he has a spinal cord injury.

*To avoid flexion of the neck, no pillow or other kind of support is placed under the head. Do not move the victim unless life-threatening conditions require it. ***Methylprednisolone****, a corticosteroid, may be given as soon as the examination and diagnosis of cord injury are made. If given within 8 hours of injury, it is believed to minimize further damage and improve the return of both motor function and sensation. *Normal saline is used for fluid replacement, and drugs such as dopamine (Intropin) may be given to sustain a sufficient blood pressure to prevent cord hypoxia.

Mobility Cause-and-Effect Concepts - figure 26-3

<-> Intracranial regulation <-> Nutrition <-> Pain <-> Gas Exchange <-> Perfusion ->Tissue integrity ->Elimination

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? A - Fluctuations in blood pressure B - Loss of cognitive function C - Ineffective cough D- Drooping eye lids

B - Loss of cognitive function Rational A - Fluctuations in blood pressure is a manifestation associated with amyotrophic lateral sclerosis. The nurse should expect a client who has MS to exhibit a fluctuation is disease manifestations that worsen with heat exposure or exertion. B - Loss of cognitive function is a manifestation associated with MS C - Ineffective cough is a manifestation associated with amyotrophic lateral sclerosis. The nurse should expect a client who has MS to exhibit ineffective bowel and bladder function. D - Drooping eyelids is a manifestation associated with myasthenia gravis. The nurse should expect a client who has MD to exhibit changes in visual acuity.

A nurse is reinforcing teaching with a client who is to have a bone scan. Which of the following statements should the nurse include? A - "You will receive an injection of radioactive isotope when the scanning procedure beings." B - "You will be inside a tube-like structure during the procedure." C - "You will need to take radioactive precautions with your urine for 24 hours after the procedure." D - "You will have to urinate just before the procedure."

D - "You will have to urinate just before the procedure." Rational A - The radioactive isotope is injected through an IV 2 to 3 hr before the scanning. B - The procedure does not use a tube-like structure as for an MRI C - Radioactive precautions for urine are not necessary follow the procedure D - The client will beed to urinate prior to the procedure. An empty bladder promotes visualization of the pelvic bones.

A nurse is reviewing the plan of care for a client who has PD. Which of the following interventions should the nurse identify as the priority. A - recommend a community support group B - Integrate a daily exercise routine C - Provide a walker for ambulation D - Schedule a swallowing evaluation

D - Schedule a swallowing evaluation Rational A - the nurse should recommend a community support group to facilitate coping with PD progression. However, another intervention is the priority B - The nurse should help the client integrate daily exercise to improve balance and cognition. However, another intervention is the priority C - The nurse should help the client obtain a walker to promote safe ambulation. However, another intervention is the priority. D - When using the airway, breathing, circulation approach to client care, the nurse determines that the priority intervention is to schedule a swallowing evaluation for the client. Impaired swallowing from loss of muscle control places the client at risk for aspiration when consuming food or beverages.

Neurologic assessment

Evaluate neurologic function by testing indicators such as mental status, motor function, electrical activity, and intracranial pressure

Renal complications. Urinary reflux from the bladder to the kidney often results from impaired bladder function.

Heterotopic ossification is bony overgrowth that may invade muscle. Assess for swelling, warmth, redness, and decreased range of motion of the extremities to detect ossification.

Spinal Cord Injury Complications Neurogenic Shock

Neurogenic shock may occur within 24 hours and is caused by loss of vasomotor tone caused by the injury; neurogenic shock is characterized by bradycardia, hypotension, venous pooling with decreased cardiac output, and occasionally paralytic ileus. Vital signs become labile.

Infection - Mechanical ventilation with intubations & Urinary catheterization for loss of bladder.

Skin breakdown. Lack of sensation and inability to move for repositioning places the patient at great risk for skin breakdown and pressure ulcers.

Mobility - Musculoskeletal System Bones *Three overarching roles

* It acts as the structural foundation for the body and as leverage to move body parts * Supports and protects tissue and internal organs * Provides attachment sites for muscles and ligaments. *Serve as a storage center for calcium and as a production center for red blood cells within the bone marrow. *The remodeling process also provides the mechanism to repair injured bones (fracture) - requires adequate nutrition, hormonal regulation, and blood supply

Mobility - Clinical Management

* Primary - Maintaining the highest level of regular physical activity possible along with optimal nutrition, keeping an ideal body weight and adequate rest - Prevent injury/trauma. Nutrition (Growth) - adequate protein and calcium - Calcium is necessary to prevent osteoporosis. * Secondary - screenings - osteoporosis, mobility screening, fall risk assessment. Screening of women age 65 years or older or have an increase fracture risk. Most common screening test is Timed Get Up and Go test (measures mobility in people who are able to walk on their own). Performance-Oriented Mobility Assessment - aids in the identification of gait and balance impairments. Greenville Early Mobility Scale - track the status of progress *Interventions - Exercise therapy, pharmacologic agents, surgical interventions, immobilization, and assistive devices. Occupational injuries (Health care workers) - establishing a culture of safety, education, and training, application of ergonomic principles in the care environment, patient-centered assessment, and integration of safe patient handling technology in the care environment.

Mobility Diagnostic Tests

* X-ray - integrity of bones and joints * CT - identifies soft tissue and bony abnormalities - musculoskeletal trauma *MRI - images of soft tissue - vertebral disk, tumor, ligaments, and cartilage * Myelogram - study of the spinal cord and nerve root * Arthrography - visualization of a joint - evaluation of bones, cartilage and ligaments. * Bone mineral density - determine the core mineral content and the density of bone * Bone scan - evaluates bone uptake - uptake is related to the metabolism of the bones. *Arthroscopy - direct visualization of the interior of a joint thought an endoscope. *Electromyography - evaluation of electrical activity generated within the muscle *Lab test - various info - functional state of muscles, bones, or joints.

Sings and Symptoms - Spinal cord injuries

*A complete severance of the spinal cord, or damage to the cord's entire thickness, results in a total loss of sensation and control in the parts of the body below the point of injury. *Severe injury to the cord above the level of the fifth cervical vertebra often is fatal if emergency care is not immediate *Interruption of the thoracic spinal cord through L1 and L2 causes paraplegia *CT scan or MRI may be performed to determine the extent of the damage and to see whether the cord is completely transected (severed).

Parkinson's Disease (PD) Bradykinesia

*A condition that causes slow movement and speech *produces poor body balance, a characteristic gait, and difficulty initiating movement. The gait is shuffling, with short steps that become quicker (Figure 24-2 Med Surg pg 554). There is decreased swinging of the arms when walking. A foot may drag or may be stiff, producing a limp. Earlier in the disease process, the patient may lean slightly to one side, propel forward uncontrollably, or fall backward. In advanced stages there is a stiff, bent-forward posture when walking.

Parkinson's Disease (PD) Sings and Symptoms

*A triad of symptoms is characteristic of PD: tremor, bradykinesia, and rigidity.

Multiple Sclerosis (MS) Treatment/Assessment

*Acute attacks are treated with intravenous (IV) methylprednisolone for 5 days, followed by oral prednisone in tapering doses *Physical Exam - testing extremity strength, visual problems, and checking reflexes *Fatigue *Altered physical mobility *Altered self-care *Altered urinary function *Altered sexual function *Altered skin integrity *Altered family coping (financial problems, changing roles, physical abilities) *Decreased self-esteem

Parkinson Disease (PD) Rigidity

*Affecting the skeletal muscles and contributing to postural changes and difficulty in movement *The face becomes blank or masklike in appearance with little or no expression. Speech becomes low in tone, monotonous sounding, and slow; enunciation becomes difficult because of the decreased dopamine and the excitatory response from the increased ACh. *Stress tends to make symptoms worse.

Mobility - Neurologic System

*All movement is coordinated by the brain through a complex process of sensing internal and external data signals, integrating these data signals, and responding by triggering motor activity. *The motor cortex in the frontal lobe of the brain is responsible for voluntary motor activity through a series of nerve impulses sent from the brain, through the spinal cord and peripheral nerves, to the target muscle *The cerebellum (base of brain) - coordinates movement, equilibrium, muscle tone, and proprioception

Mobility - Pharmacologic Agents

*Anti-inflammatory agents - corticosteroids - NSAIDS - reduce inflammation * Analgesic and muscle relaxants - opioids - NSAIDS - aspirin - relief from discomfort by eliminating muscle spasms. * Supplements - Vitamin D and Calcium - prevention treatments for osteoporosis - Bisphosphonates are antiresorptive agents that slow or stop the reabsorptoin of calcium from the bones.

Amputations

*Are elective due to complications of peripheral vascular disease and arteriosclerosis, congenital deformities, chronic osteomyelitis, or malignant tumor, or traumatic due to an accident. *The level of the amputation is determined by the presence of adequate blood flow needed for healing. *Accidents, war or injury is the primary cause *Other - vasospastic disease, malignancy, and infection of the extremity.

Mobility Definitions

*As a state or quality of being mobile or moveable *Immobility refers to an inability to move *Impaired physical mobility describes a state in which a person has a limitation in physical movement but is not immobile. *There are times when immobility or immobilization is therapeutic. *Deconditioned is used to describe a loss of physical fitness (prolonged bed rest) *The disuse syndrome describes the predictable adverse effect on body tissue and functions associated with sedentary lifestyle and inactivity (cardiovascular vulnerability, obesity, musculoskeletal fragility, depression, and premature aging. *A patient with an immobilized extremity can be mobile. Also, because mobility is on a continuum, a change in mobility may be temporary *Relies on bones, joints, articular cartilage, tendons and ligaments, skeletal muscle, and the mechanics of muscle contraction

Spinal Cord Planning

*Bladder and bowel training programs, as well as instruction in moving from bed to chair—and other aspects of self-care—may be necessary. Realistic goals should be set for the patient*The overall goal is to promote as much independence as possible

Mobility - Psychological Effects

*Boredom, depression, feelings of helplessness/hopelessness, grieving, anxiety, anger, disturbed body image, and decreased verbal and nonverbal communication *Especially concerning among children - Immobilization can interfere with intellectual and psychomotor function. *Developmental regression is common *In some cases hallucinations occur

Consequences of Immobility Concepts Table 26-1

*Cardiovascular system - Reduced cardiac capacity, decreased cardiac output, orthostatic hypotension, venous stasis, DVT *Respiratory system - Reduced lung expansion, atelectasis, pooling of respiratory secretions *Musculoskeletal system - Reduction in muscle mass and atrophy, contracture of joints, bone demineralization *Integumentary system - skin breakdown *Gastrointestinal system - Reduction peristaltic motility, constipation *Urinary system - Renal calculi, urinary stasis, infection

Neurologic diagnostic procedures

*Cerebral angiography - provides visualization of the cerebral blood vessels. Used to assess the blood flow to and within the brain, identify aneurysms, and define the vascularity of tumors. *CT - provides cross-sectional images of the cranial cavity. Identify tumors and infarctions, detect abnormalities, monitor response to treatment, and guide needles used for biopsies. *Electroencephalography - Assesses the electrical activity of the brain and is used to determine if there are abnormalities in brain wave patterns. Performed to identify and determine seizure activity & detecting sleep disorders and behavior changes. Clients should be sleep-deprived, because this provides cranial stress, increasing the possibility of abnormal electrical activity. *Glasgow Coma Scale - Neurologic function. Level of consciousness and monitor response to treatment. Determining changes in the level of consciousness for clients who have head injuries, space-occupying lesions or cerebral infarctions, and encephalitis. Eye opening (E) - 4-1, Verbal (V) - 5-1, Motor (M) - 6-1 = E+V+M = Total GCS (Max of 15) - Less than 8 = severe head injury, 9-12 = moderate head injury, 13 + = minor head trauma *Intracranial pressure monitoring - device inserted into the cranial cavity that records pressure and is connected to a monitor. Early identification and treatment of increased intracranial pressure. Comatose or have GCS scores of 8 are candidates for ICP monitoring. *Lumbar puncture - A small amount of CSF is withdrawn from the spinal canal. Used to detect the presence of some disease (MS, syphilis, meningitis), infections, and malignancies. Used to reduce CSF pressure, diagnostic tests or administer medications/chemo *MRI - Provides cross-sectional images of the cranial cavity. Scan a client who has an artificial device. Used to detect abnormalities, monitor response to treatment, and guide needles used for biopsies. Capable of discriminating soft tissue from tumor or bone, tumor size and blood vessel location. *PET & SPECT - Produce three-dimensional images of the head. Initiates metabolic activity. Capture of regional metabolic process, useful in determining tumor activity and response to treatment. Determine the presence of dementia. *X-Ray - Capture images of the internal structures of an individual. Can reveal fractures, curvatures, bone erosion and dislocation, and possible soft tissue calcification, all of which can damage the nervous system.

Spinal Cord Injury Immobilization and Surgery

*Cervical spinal cord injury is usually treated with traction to immobilize the affected vertebrae and maintain alignment. *Selecting the type of bed to be used for a patient with spinal cord injury depends on many factors.

Mobility - Surgical Interventions

*Curative or palliative (depends on underlying cause) *Arthroscopic procedures, open and/or closed reduction of a fracture with or without external and/or internal fixation, amputation, synovectomy, osteotomy, debridement, arthroplasty, arthrodesis, diskectomy, and spinal fusion.

Parkinson's Disease (PD) Complications

*Dysphagia may develop, and mobility becomes severely limited as the disease progresses. Problems of immobility occur. Constipation, urinary incontinence, and insomnia are also common. *Coaching the patient to drop the chin when swallowing helps prevent choking.

Care of Immobilized Patient

*Emphasize the need for early mobility *Barriers. - Patients - excessive sedation, delirium, morbid obesity, multiple invasive devices. Staff - fragmented care, availability of adequate equipment, time constrains, adequate number of providers, and concerns for patient safety. *Progressive mobility - series of gradual progressive interventions and activities that include position, turning, continuous lateral rotation therapy, ROM, head elevation, tilt table, chair position, dangling, and ambulation. *Skin is regularly monitored and examined for evidence of adequate circulation. *Immobilized patients are at risk for stasis pneumonia - coughing and deep breathing are standard. Rotational bed therapy and CLRT shown to reduce pneumonia. *Bed exercises should be encouraged - flexion and extension of the foot (prevent venous stasis) *Trapeze bar encourage uses for pull-up exercise *ROM - minimize complication of joints *Active ROM - preformed by patient *Passive ROM - preformed by staff\ *Goal of exercised is rehabilitative or preventive, and it is often sone in multiple combinations.

Mobility - Risk Factors

*Greatest risk for impaired mobility is older adults (falls - challenges regaining full mobility) *Acute and chronic conditions, chronic pain, and injury/trauma, orthopedic injury, congenital deformities, neurologic disorders, strokes, head injury, spinal injury or deformities, nutritional deficiencies, cardiopulmonary conditions, and end-stage cancer *Medication side effects - corticosteroids and chemotherapy

Spinal Cord Injury Muscle Spasms

*Immediately after a spinal cord injury, the patient will usually have a flaccid type of paralysis. Later, as the cord adjusts to the injury, the paralysis will become spastic, and there will be strong, involuntary contractions of the skeletal muscles. *The patient and family may interpret these spasms as a return of voluntary function of the limbs and will 515have false hopes of complete recovery.*The nurse or the provider must explain to them that these spasms are common in patients with spinal cord injuries.

Spinal Cord Injury Psychological Care

*In caring for these patients, use active listening, be supportive, and help the patient to focus on positive strengths and the possibilities for the future. *Stages of Grief Shock and denial Anger Bargaining Depression Adjustment *encouraged to verbalize concerns and questions and should be given guidance about alternative ways to express sexuality and meet sexual needs.

Spinal Cord iInjury Respiratory Management

*Intubation and mechanical ventilation are often required to sustain life in patients with an injury at C5 or above. *Mechanical ventilation relieves the muscle work of breathing and conserves the patient's energy during the emergent phase of the injury.

Autonomic dysreflexia (hyperreflexia). AD

*Is an uninhibited and exaggerated reflex response of the autonomic nervous system to some form of stimulation that occurs in 85% of all patients who have spinal cord injury AT OR ABOVE the level of the sixth thoracic vertebra **(T6).*** *The AD response is potentially dangerous to the patient, because it can produce vasoconstriction of the arterioles with an immediate elevation of blood pressure. *Careful attention must be paid to keeping the bladder from becoming overdistended. If the patient is on bed rest, check the catheter and drainage tubing for the indwelling catheter every couple of hours.

Mobility - Musculoskeletal System Joints

*Joints provide stability to bones and allow skeletal movement *Types of movement - flexion, extension, rotation, adduction, abduction, supination, and pronation *Three classifications of joins - 1 - Synarthrosis joints - non-moveable) 2 - Amphiarthrosis joints - Slightly moveable 3 - Diarthrosis joints - freely moveable *Fibrous joints serve to hold bones together in place with connective tissue *Cartilaginous joints features cartilage material that holds the joint together and provides some movement *Joints that allow the most movement are also the most complex *Without cartilage, significant friction and pain result from joint movement

Drugs Commonly Used for Patients With Parkinson Disease

*Levodopa (L-dopa)Levodopa-carbidopa (Sinemet)Bromocriptine mesylate (Parlodel) (Decrease presence of tremor, rigidity, and bradykinesia and improve motor function) *Cogentin - Decrease tremor *MAOI - Decrease presence of tremor, rigidity, and bradykinesia and improve motor function

Parkinson's disease (PD) Diagnosis

*MRI scans of the brain may be performed to rule out other neurologic disorders *Single-photon emission computed tomography (SPECT) can display the reduced uptake of dopamine

Multiple Sclerosis (MS)

*Multiple sclerosis (MS) is a chronic inflammatory disease that causes demyelination in the central nervous system (CNS). *There is no cure *Characterized by periods of remission and exacerbation *MS is considered to be an autoimmune disease, in which the immune system attacks healthy CNS tissue. *Symptoms typically appear between 15 and 50 years of age *Myelin is a protective sheath that insulates axons and assists impulse transmission. Axons transmit electrical impulses from one neuron to the next. In patients with MS, plaques form along the myelin sheath, causing inflammation. When myelin is eroded by inflammation and replaced by scar tissue (demyelination), nerve impulses cannot travel along the damaged neurons. Thus the muscles served by the affected nerves do not receive the impulses they need to perform in a well-coordinated and useful manner.

Level of injury C1-C3

*No respiratory function; usually fatal unless immediate emergency help is available *Respirations stimulated with phrenic pacemaker. Can manipulate electric wheelchair with breath, chin, or voice control.

Parkinson's Disease (PD) Planning, Implementation, and Evaluation

*Nursing care focuses on preventing complications of PD, drug therapy, enhancing voluntary movement, and safety. Constipation is a problem and requires the addition of fiber to the diet and an increase in fluids to at least 3000 mL per 24 hours. *Grasp coins (intentional action), walking thinking about imaginary lines to follow, imagining stepping over something helps prevent "freezing", assume correct posture, not using a pillow in bed, sleep prone *The physical therapist will institute an exercise program to help the patient maintain muscle function and promote joint mobility. *Degeneration of cognitive skills occurs in the late stages of PD. *Falls are common, and safety is a major factor. (Use canes/walker, remove loose carpet, add grab bars in the bathroom, raised toilet seat, & caution against carrying hot liquids)

Multiple Sclerosis (MS) Implementation and Evaluation

*Ongoing care by an interdisciplinary team focuses on safety, prevention of complications, assistance with physical therapy, and emotional support. *Calcium and vitamin D should be included in the diet to help prevent osteoporosis that may result from the IV steroid treatments. Medications to decrease stomach acid and prevent ulceration from the steroids may be administered (histamine [H2]-receptor blockers or proton pump inhibitors). *The routine should include daily physical exercise balanced by rest periods to prevent fatigue. *Education about the unpredictability of the disease and the need to prevent stress, infections, and fatigue *Local support groups

Mobility Exemplars

*Osteoarthritis - Changes lead to pain, swelling, and reduced mobility of the joint. *Rheumatoid Arthritis - Joint inflammation leads to erosion of the membrane and cartilage, causing, pain, swelling, and joint deformity. Juvenile Idiopathic Arthritis - Chronic inflammation of joints from autoimmune conditions. Joint deformity, mobility impairments, and physical disability. *Bone Fracture - Leads to a reduction or loss in movement and pain *Parkinson's Disease - Neurologic disorder associated with a loss of dopamine production in the brain. Muscle tremor, rigidity of the extremities and trunk, slowness of movement, and impaired coordination and balance. *Spinal Cord Injury - Result in temporary or permanent neurologic impairment and mobility. Causes - motor vehicle accidents, falls, sports injury, or personal violence. *Low Back Pain - MOST COMMON - caused by muscle, bone, or nerve irritation from a variety of conditions, including muscle strain or spasm, degenerative conditions, and trauma, late-term pregnancy.

Parkinson Disease (PD)

*PD is considered a major health problem because of its crippling effects. *It is a progressive disorder, beginning rapidly at first and then advancing more slowly. It affects more men than women and occurs most commonly after age 60 years. *The specific cause of PD is unknown (idiopathic), but it involves degeneration of the dopamine-producing neurons in the substantia nigra of the midbrain and the presence of Lewy bodies *Secondary PD can be drug induced (eserpine-type antihypertensives such as methyldopa, phenothiazines, some tranquilizers such as the butyrophenones (e.g., haloperidol [Haldol]), some antiemetics, methamphetamine, and a few other drugs.) *PD affects the extrapyramidal system, in particular the motor structures in the basal ganglia. *Dopamine inhibits the function of these neurons to allow for control of voluntary movement *There is usually a balance between these 554neurotransmitters. The degenerative changes in the basal ganglia that occur in PD lead to a decrease in dopamine.

Mobility assessment

*Presence of pain with movement *Recent changes in mobility or problem with balance *Presence of fatigue *Recent falls *Recent changes in ability to complete activity of daily living *Objective data - gait and body posture, joints (size, symmetry, and strength of muscle), rage of motion, developmental milestones

Mobility - Musculoskeletal System Muscles

*Skeletal muscle differs from other types of muscles in that it is under voluntary control *Five Factors 1 - nerve impulses reaching the muscle 2 - muscle fibers' response to nerve stimulus 3 - proprioception 4 - mechanical load 5 - joint mobility *Impairment of ay one of these factors negatively impacts purposeful movement *Nerve impulses reach skeletal muscle from the spinal cord and peripheral nerves via motor neurons. *Muscle movement occurs in response to nerve stimulation of the muscle fibers triggering muscle contraction. *If one group contracts, another group relax (flexion of the elbow to move the forearm up requires contraction of the biceps muscles and relaxation of the triceps muscle) *If both are contracted at the same time no movement occurs.

Parkinson Disease (PD) Surgical Treatment

*Stereotactic neurosurgery may be performed if the drug therapy fails (In one such procedure the area in the thalamus that is causing the involuntary movements is destroyed) *DBS uses electrode implants to provide electrical shocks that control tremors by blocking them. The device that delivers the shocks can be adjusted as the patient's symptoms change or worsen

Parkinson's Disease (PD) Tremors

*The first, tremor, occurs when the body is at rest, decreases when there is voluntary movement, and is absent when the patient is asleep. The tremor is most often a "pill-rolling" motion of the thumb against the fingers. *When the patient experiences stress and emotional tension, the tremor becomes more pronounced.

Spinal Cord Injury Rehab

*The physical therapist, occupational therapist, psychologist, physician, respiratory therapist, pharmacist, and ancillary personnel will collaboratively plan the patient's care. The patient and family are often invited to participate in the planning process. *Functional Electrical Stimulation (FES) is used to generate neural activity and overcome lost function. The system stimulates muscles to make walking motions. The patient is suspended in a harness to support body weight and is retrained to walk using a treadmill.

Mobility Age-related differences Variations

*The size and composition of muscles undergo changes as a result of physical growth and development throughout childhood, and they are the major factor in weight gain during adolescence. *Changes occur with aging - a thinning of vertebral disks, shortening of the spinal column, and onset of kyphosis with spinal column compression occur. Bone density decrease and becomes brittle (females & more susceptible to fracture) *Changes in mobility can be temporary, long term, or permanent and are influenced by general health status (neurologic or musculoskeletal system) *Many conditions lead to changes in mobility, including acute illness or injury (influenza), debilitating chronic conditions (cardiovascular & pulmonary). *Conditions that specifically lead to mobility impairments -neurologic (brain/spinal cord), musculoskeletal (bones/joints/muscles), or a combination of both

Parkinson Disease (PD) Treatment

*Treatment of PD usually includes drug therapy, physical therapy, and considerable emotional support. *Currently, medications for PD all involve controlling levels of dopamine. Drug therapy aims to provide dopamine to the basal ganglia and thus reduce symptoms. *MAOIs block the metabolism of dopamine, leaving more dopamine in circulation. *Successful treatment usually involves a combination of these therapies. *When a patient with PD has been prescribed selegiline (an MAOI), caution him against eating foods containing *****tyramine****, such as aged cheeses, anything fermented, smoked fish or meat, yeast extract, some imported beers, Chianti wine, dietary protein supplements, and soy sauce. *When disability is present, L-dihydroxyphenylalanine (L-dopa, or levodopa) or a combination of levodopa and carbidopa (Sinemet) is given. Sinemet is given in increasing doses until control of the symptoms is achieved; however, side effects can be troublesome

Amyotrophic Lateral Sclerosis (ALS) Lou Gehrig Disease

*is a progressive neuromuscular disease characterized by degeneration of the gray matter in the anterior horns of the spinal cord and the lower cranial nerves. After degeneration, electrical and chemical messages generated in the brain cannot reach the muscles to activate them. *One of the first clinical manifestations of ALS is weakness of the voluntary muscles, especially of the distal muscles of the extremities. Some patients may notice difficulty swallowing and speaking clearly because of oropharyngeal weakness. As the disease progresses, there is atrophy of the muscles. Until atrophy is complete, however, there may be spontaneous contractions or spasticity of the muscles and abnormal sensations (paresthesias), such as tingling or prickling. *Death typically results from respiratory infection and dysfunction as weakness and atrophy of the respiratory muscles impede normal respiration and mechanisms to clear bacteria and secretions from the lungs. *The drug riluzole (Rilutek), a glutamate antagonist, has been shown to slow the progression in certain patients (NINDS, 2014). Ultimately impaired breathing requires a tracheostomy and mechanical ventilation.

Multiple Sclerosis (MS)

- Neurological disease -Impaired and worsening function of voluntary muscles -Autoimmune disorder that affects nerve cells in the brain and spinal cord. - Plaque damages the myelin sheath and interferes with impulse transmission between the CNS and the body. -relapsing and remitting -2-3 x more often in females - Pain or paresthesia -Tinnitus, vertigo -Muscle spsticity Nystagmus

Spine and Spinal Cord Injuries Classified according to their anatomic location

-Cervical -Thoracic -Lumbar -Sacral *Whatever the cause of spinal cord injury, motor and sensory losses may occur. *The amount of loss of function and sensation depends on the level and extent of injury to the spinal cord

Cord injury is caused by

-compression -pulling and twisting -tearing of the cord *COMPLETE injuries result in loss of function BELOW the level of the injury *INCOMPLETE injuries result in various degrees of function and sensation *Extreme flexion or hyperextension of the neck, or falling on the buttocks all may cause spinal cord damage *Edema peaks in 2-3 days and subsides in about 7 days after injury *Hemodynamic instability with drops in BP may cause decreased blood flow, and hypoxia in the cord increases the initial damage.

The provider discusses the treatment options with a patient newly diagnosed with PD. The patient asks, "What will happen to me"? An appropriate response would be: 1 - "You seem worried. Let's talk about your concerns." 2 - "Your provider can fully explain you condition." 3 - "You will be all right." 4 - "We all eventually get there."

1 - "You seem worried. Let's talk about your concerns." Rational The patient is worried and probably scared. This is the best response to allow him to express concerns and ask questions. (2, 3, 4) Do not address his need to verbalize his concerns.

A patient is admitted for progressive muscle weakness in the lower extremities. The patient complains of tingling and numbness in the hands. The patient recovered from the flu a week ago. Which intervention(s) should be anticipated in the care of this patient? Select all 1 - Medication for pain and discomfort 2 - Immediate need for physical therapy exercise 3 - Possible need for ventilatory assistance 4 - Need for airway suctioning 5 - Administration of muscle relaxants

1 - Medication for pain and discomfort 3 - Possible need for ventilatory assistance 4 - Need for airway suctioning Rational The symptoms indicate Guillain-Barré syndrome (GBS). (1) Pain is a problem with this disorder. (2) Soon, the nerves that control respiration may be affected with weakness, and ventilatory support may become necessary. (3) It becomes more difficult for the patient to clear respiratory secretions, and so suctioning is necessary. (5) Muscle spasms are a common symptom with GBS.

Instructions for a patient with a "slipped disk" with acute pain and sciatica should include 1 - using ice packs on the area of back pain for 5 to 10 minutes each hour while awake for the first 48 hours 2 - resting in bed for 2 to 3 days and walking every hour even if walking causes more pain 3 - obtaining a massage each day to loosen the muscle spasms in the back 4 - not lifting anything heavier that 10 lb for several weeks.

1 - using ice packs on the area of back pain for 5 to 10 minutes each hour while awake for the first 48 hours Rational (1) Ice packs are applied for 5 to 10 minutes at a time each hour for the first 48 hours to reduce muscle spasm in the back. (2) Resting in bed is discouraged. (3) Massage will be painful. (4) The acute pain should to last several weeks.

Treatment of spinal cord injury 4 main objectives

1. To save the victim's life 2. To prevent further injury to the cord by careful handling of the patient 3. To repair as much of the damage to the cord as possible 4. To establish a routine of care that will improve and maintain the patient's state of health and prevent complications, so that eventual physical, mental, and social rehabilitation is possible As soon as an injury to the spinal cord occurs, the patient must be handled with extreme care.

A 40-year-old man with a T4 spinal cord injury suddenly complains of severe headache, increased pulse rate, sweating, and flushing above the level of the spinal cord lesion and "goose bumps" below the level of injury. Which immediate nursing action(s) should be included? Select all 1 - Place flat in bed 2 - Identify the cause of stimulation 3 - Decrease blood pressure 4 - Provide measures to facilitate bowel movement 5 - Clamp indwelling catheter

2 - Identify the cause of stimulation 3 - Decrease blood pressure 4 - Provide measures to facilitate bowel movement Rational (2) Identify and gently relieve the cause of the autonomic dysreflexia reaction, (3) decrease the blood pressure by elevating the head of the bed 45 degrees or sit the patient up, and (4) institute measures to evacuate the bowel, (1, 5) will not resolve the problem and may exacerbate it.

A nurse observes a nursing assistant feed a dysphagic patient. Which action by the nursing assistant indicated a need for further instruction and guidance? 1 - The wall suction is turned on and readily available 2 - The patient is propped up with one pillow 3 - The food is cut into small, bite-size pieces 4 - The nursing assistant coaches the patient to drop the chin

2 - The patient is propped up with one pillow Rational (2) The dysphagic patient should eat in as upright a position as possible. That is not achieved with the use of only one pillow. When the patient is upright, gravity helps with swallowing. (1) The wall suction is turned on to be available in case of choking. (3) Food in smaller pieces is more easily chewed and swallowed. (4) Dropping the chin assists in swallowing.

The student nurse is assisting the nurse in turning a patient who is in cervical traction. What is most important for the LPN/LVN to instruct the student to do when assisting in turning the patient? 1 - Flex the knees and hips before turning the patient. 2 - Support the patient's head with a pillow so that his neck is flexed. 3 - Turn the patient slowly and as one unit to avoid twisting the spine. 4 - Place the patient's back in traction so that the spine will be kept slightly flexed.

3 - Turn the patient slowly and as one unit to avoid twisting the spine. Rational One of the most important interventions when turning a patient in traction, or turning any patient with a spinal cord injury, is to logroll the patient in order to avoid twisting the vertebral column and further damaging the spinal cord. Nurses should always assist in turning a patient with a spinal cord injury; this intervention should never be delegated to assistive personnel.

During a neurologic examination, a patient demonstrates difficulty initiating movement. The steps are short with quick cadence. Arm swings are decreased with subsequent steps. The clinical findings are referred to as: 1 - muscle atrophy 2 - akinesia 3 - rigidity 4 - tremors

3 - rigidity Rational (3) Difficulty initiating movements; altered gait with short, jerky steps; and decreased arm swings are characteristic of a patient who has Parkinson disease and rigidity. (1) Muscle atrophy is shrinking of the muscles. (2) Akinesia is loss of voluntary movement. (4) Tremors are involuntary rhythmic muscle contraction and relaxation.

A 30-year-old man is admitted to the emergency department after a motor vehicle accident. After examination, the patient, the patient is diagnosed with a T6 spinal cord injury. He has flaccid paralysis, slowed heart rate, low blood pressure, and no bowel sounds. The patient must be developing? 1 - autonomic dysreflexia 2 - muscle spasms 3 - spinal shock 4 - diabetes insipidus

3 - spinal shock Rational (3) Spinal shock is characterized by flaccid paralysis and loss of reflex activity and of sensation below the level of the injury. (1) Autonomic dysreflexia is characterized by excessively high blood pressure. (2) Muscle spasms cause pain in muscular areas. (4) Diabetes insipidus is characterized by excessive thirst and excretion of large amounts of severely dilute urine.

A 45-year-old patient newly diagnosed with MS asks about his prognosis for the future Teaching about the future might include starting: 1 - "The condition is a progressive neurologic disease, and you will likely end up using a wheelchair or scooter. You might start equipping your house to be wheelchair accessible." 2 - "With the new immune-modifying drugs available as treatment, you will not even be able to tell you have the disease." 3 - "MS may being with exacerbations and remissions, but it will eventually develop into a progressive disease, affecting your entire neurologic system and, thus, you whole body." 4 - "The condition is a periodic demyelination of the central nervous system, often with periods of remissions and exacerbations. It is a manageable disease, an there are many patients who live active and rewarding lives. Use of the new immune-modifying agents will help reduce exacerbations."

4 - "The condition is a periodic demyelination of the central nervous system, often with periods of remissions and exacerbations. It is a manageable disease, an there are many patients who live active and rewarding lives. Use of the new immune-modifying agents will help reduce exacerbations." Rational (4) Multiple sclerosis (MS) is a manageable disease, and the new available drugs help reduce the number of exacerbations, thus improving quality of life. (1) Only about 25% of people with MS use wheel chairs or scooters—many are able to walk unassisted while some use walking aids, such as canes or crutches. (2) Even though he knew immune-modifying drugs are effective at reducing exacerbations, it does not mean the patient will not experience any symptoms or exacerbations; (3) while some people develop progressive disease, the majority of MS patients do not.

A patient experienced injury to the spinal cord in the cervical region, with paralysis and loss of sensory perception in both legs and both arms. What term is used to describe this condition? 1 - Paraplegia 2 - Hemiplegia 3- Homoplegia 4 - Quadriplegia

4 - Quadriplegia Rational Injury to the spinal cord in the cervical region with paralysis and the loss of sensory perception in both legs and both arms is quadriplegia. Paraplegia is paralysis of both legs. Hemiplegia is paralysis of one half of the body. Homoplegia is not used to describe paralysis in the body.

A nurse is reviewing the plan of care for a client who is scheduled for cerebral angiography with contrast dye. Which of the following statements by the client should the nurse report to the provider? Select all A - "I think I might be pregnant." B - "I take warfarin." C - "I take antihypertensive medication." D - "I am allergic to shrimp." E - "I ate a light breakfast this morning."

A - "I think I might be pregnant." B - "I take warfarin." D - "I am allergic to shrimp." E - "I ate a light breakfast this morning." Rational A - The nurse should report the client's statement of possible pregnancy to the provider because the contrast dye can place the fetus at risk. B - The nurse should report that the client is taking warfarin to the provider due to the potential for bleeding following angiography C - There is no contraindication related to contrast dye for a client who is taking antihypertensive medication. D - The nurse should report a client's report of allergy to shrimp, which is a shellfish, to the provider because of a potential allergic reaction to the contrast due. E - The nurse should report a client's intake of food to the provider since the client should remain NPO for 8 to 12 hr prior to the procedure.

A nurse is reinforcing teaching with the family of a client who has Parkinson's disease and a new prescription for bromocriptine. Which of the following statements by a family member should the nurse identify as understanding of the teaching? A - "This medication can cause dizziness" B - "This medication turns into dopamine once in the brain." C - "We should see improvement mobility in 2 to 3 days" D - "We should avoid dopaminergics while taking medication."

A - "This medication can cause dizziness" Rational A - Orthostatic hypotension is a common adverse effect of bromocriptine, a dopamine receptor agonist. The family members should have the client rise slowly when standing up to decrease the risk for dizziness and lightheadedness. B - The nurse should remind the family member that bromocriptine stimulates the body to release dopamine. Dopaminergic medications convert to dopamine in the brain. C - The nurse should remind the family that medications to treat PD can take weeks to become effective in improving manifestations of the disease D - The nurse should remind the family that dopamine agonists, such as bromocriptine are given along with a dopaminergic medication to increase effectiveness.

A nurse is collecting data from a client who has a new diagnosis of multiple sclerosis. Which of the following findings should the nurse expect? Select all A - Areas of paresthesia B - Involuntary eye movement C - Alopecia D - Increased salivation E - Ataxia

A - Areas of paresthesia B - Involuntary eye movement E - Ataxia Rational A - Areas of loss of skin sensation area. finding in a client who has MS B - Nystagmus is a finding in a client who has MS C - Hair loss is not a finding in a client who has MS D - Dysphagia (swallowing difficulty) is a finding in a client who has MS E - Ataxia occurs in the client who has MS as muscle weakness develops and there is loss of coordination

A nurse is contributing to the plan of care for a client who will undergo an electromyography (EMG). Which of the following actions should the nurse include in the plan of care? Select all A - Check for bruising B- Apply ice to insertion sites C - Determine whether the client take a muscle relaxant D - Instruct the client to flex her muscles during needle insertion E - Expect swelling, redness, and tenderness at the insertion site.

A - Check for bruising B- Apply ice to insertion sites C - Determine whether the client take a muscle relaxant D - Instruct the client to flex her muscles during needle insertions Rational A - Some bruising can occur at the needle insertion sites B - The nurse should apply ice to the insertion sites to prevent hematoma development C - The nurse should collect data regarding the client's medications to determine whether she takes a muscle relaxant, which can decrease the accuracy of the test results. D - The nurse should ask the client to flex her muscles for an easier insertion of the needle into the muscle. E - The nurse should instruct the client to report swelling, redness, and tenderness at the insertion sites to the provider because this can indicate an infection.

A nurse is presenting information to a group of clients at a health fair about measures to reduce the risk of amputation. Which of the following information should the nurse provide? select all A - Clients who smoke should consider smoking cessation programs B - Clients who have diabetes mellitus should maintain blood glucose within expected reference range. C - Unplug electrical equipment when preforming repairs D - Clients who have vascular disease should maintain good foot care E - Wait 2 hr after taking pain medication before driving

A - Clients who smoke should consider smoking cessation programs B - Clients who have diabetes mellitus should maintain blood glucose within expected reference range. C - Unplug electrical equipment when preforming repairs D - Clients who have vascular disease should maintain good foot care Rational A - Smoking cessation can decrease the development of arteriosclerosis and possible amputation of the lower extremity B - Regulating blood glucose levels within a normal reference range prevents the development of arteriosclerosis and possible amputation of a lower extremity C - Unplugging electrical equipment when preforming repairs prevents electrocution and injury to an extremity, which can lead to amputation D - Maintaining good foot care prevents infection, which can result in amputation E - Driving under the influence of pain medication can lead to an accident or injury to an extremity, requiring amputation

During the advanced stages of amyotrophic lateral sclerosis (ALS), which service would be most beneficial to the family and patient? A - Hospice services B - In-home physical therapy C - Pulmonary rehabilitation program D- Nursing visits from a home health care agency

A - Hospice services Rational ALS is a progressive disease with no known cure. The prognosis for most patients with ALS is death within about 3 years from the onset of symptoms. In the advanced stages of ALS, the patient and family would most benefit from the services offered by hospice. In-home physical therapy, home health care, and pulmonary rehabilitation are beneficial in the earlier stages of the disease.

A nurse is contributing to the plan of care for a client who is postoperative following an arthroscopy of the knee. Which of the following actions should the nurse take? Select all A - Inspect color and temperature of the extremity B - Apply warm compresses to incision site C - Place pillows under the extremity D - Administer analgesic medication E - Check pulse and sensation in the foot

A - Inspect color and temperature of the extremity C - Place pillows under the extremity D - Administer analgesic medication E - Check pulse and sensation in the foot Rational A - Inspecting color and temperature of the affected extremity helps identify alterations in circulation B - Cold compresses on the incisional site for the first 24 hr help decrease swelling and pain C - Elevating the leg helps decrease swelling and pain in the affected extremity D - Administering analgesic medication helps relieve joint pain in the affected extremity E - Checking pulse and sensation of the affected extremity helps identify alterations in circulation

A nurse is collecting data from an older adult client who has arteriosclerosis and is scheduled for a right lower extremity amputation. Which of the following are expected findings in the affected extremity? Select all A - Skin cool to touch from mid-calk to the toes B - Lower leg appearing dusky when client is sitting C - Palpable pounding pedal pulse D - Lack of hair on lower legs E - Blackened areas on several toes

A - Skin cool to touch from mid-calk to the toes B - Lower leg appearing dusky when client is sitting D - Lack of hair on lower legs E - Blackened areas on several toes Rational A - The client can have coolness of the affected extremity where decreased vascularization starts B - The affected extremity can become dusky when sitting due to decreased vascularization of the extremity C - The client will have a lack of or diminished pedal pulse of the affected extremity due to decreased vascularization D - The client can have decreased hair growth on areas of the affected extremity due to decreased vascularization E - The client can have blackened areas on several toes suggestive of gangrene due to decreased vascularization to the affected extremity

The nurse is assessing a patient admitted for a work-up to rule out ALS. Which symptoms are typically exhibited in a patient with ALS? Select all A- Muscle pain B - Slurred speech C- Muscle spasticity D - Decreased sensation E - Difficulty swallowing

A- Muscle pain B - Slurred speech C- Muscle spasticity E - Difficulty swallowing Rational Muscle pain and spasticity, slurred speech, and difficulty swallowing are all symptoms of ALS. Decreased sensation is not a symptom of ALS.

Parkinson Disease (PD) Progressively debilitating disease

Affects motor function Tremor muscle rigidity bradykinesia (slow movement) postural instability (More common in males)

Spinal Cord Injury Urinary Management

An indwelling urinary catheter is inserted to prevent bladder distention and protect the skin from reflex bladder emptying.

A nurse is reinforcing teaching with a client who is scheduled for a CT scan with contrast. Which of the following statements by the client indicates understanding of the teaching? A - "I should not have caffeine 48 hr before the procedure." B - "I will have my kidney function checked before the test." C - "I should tape my wedding band in place before the procedure." D - "I will have my brain activity monitored during the test.

B - "I will have my kidney function checked before the test." Rational A - The nurse should recognize that a client should withhold stimulants, such as caffeine, 24 to 48 prior to electroencephalograph. The client should be NPO 3-4 hr prior to a CT scan B - Contrast media used for the CT is excreted by the kidneys. The nurse should check kidney function prior to the CT to prevent hard to the client. C - The nurse should remind the client to remove jewelry and all forms of metal prior to the procedure to promote accurate results. D - The nurse should recognize that a client will undergo monitoring of brain activity during electroencephalography.

A nurse is reinforcing preoperative teaching with a cleint who is to undergo an arthroscopy to repair a shoulder injury. Which of the following statements should the nurse include? Select all A - "Avoid damage or moisture to the cast on your arm." B - "Inspect your incision daily for indications of infection C- "Apply ice packs to the area for the first 24 hr" D - "Keep you arm in a dependent position" E - "Perform isometric exercises"

B - "Inspect your incision daily for indications of infection C- "Apply ice packs to the area for the first 24 hr" E - "Perform isometric exercises" Rational A - The client should wear a sling to immobilize the arm of the affected shoulder to limit activity and promote healing. B - The client should inspect the incision for evidence of infection (redness, swelling, purulent drainage) C - The client should apply ice packs to the affected area for the first 24 hr to reduce swelling and discomfort D - The client should elevate the affected extremity for 12 to 24 hr to reduce swelling E - The client should preform the isometric exercises as prescribed and directed.

A nurse is reinforcing teaching with clients at a health fair about dual-energy x-ray absorptionmetry (DXA) scans. Which of the following information should the nurse include in the teaching? Select all A - "The test requires the use of contrast material." B - "The hip and spine are the usual areas the device scans." C - "The scan detects osteoarthritis." D - "Bone pain can indicate a need for a scan." E - "At age 40, you should have a baseline scan."

B - "The hip and spine are the usual areas the device scans." Rational A - DXA scan does not require contrast material B - The most common areas for a DXA scans are the hip and spine for more clear visualization for a large area of bone C - A DXA scan detects osteoporosis, not osteoarthritis. D - Bone pain, loss of height, and fractures can indicate the need for a DXA scan E - A baseline scan at age 40 is helpful for comparison with a scan during the postmenopausal period

A nurse is reinforcing teaching with a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching? A - "Do not wash you hair the morning of the procedure." B - "Try to stay awake most of the night prior to the procedure." C - "The procedure will take approximately 15 minutes." D - "You will need to lie flat for 4 hours after the procedure."

B - "Try to stay awake most of the night prior to the procedure." Rational A - The nurse should instruct the client to wash her hair on the morning of the procedure to remove oils, gels, and sprays, which can affect the EEG readings. B - The nurse should tell the client to remain awake most of the night to provide cranial stress and increase the possibility of abnormal electrical activity. C - The nurse should inform the client that the procedure will take approximately 45 min to 2 hr D - The nurse should include that the client can resume normal activity immediately following the procedure.

A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? Select all A - Use the Glasgow Coma Scale to evaluate the client B - Assist the client to a supine position C - Administer an opioid medication D - Encourage the client to increase fluid intake E - Remove the bandage on the client's puncture site.

B - Assist the client to a supine position C - Administer an opioid medication D - Encourage the client to increase fluid intake Rational A - The GCS is used to assess a client's level of consciousness and is not necessary following a lumbar puncture B - The nurse should assist the client to a supine position, which can relieve a headache following a lumbar puncture. C - The nurse should administer an opioid medication for a client's report of headache pain D- The nurse should encourage an increased fluid intake to maintain a positive fluid balance, which can relieve a headache following a lumbar puncture. E - Leaking CSF can cause a headache following lumbar puncture. The client can require a patch to seal the puncture site if the headache doesn't resolve.

A nurse is using the Glasgow Coma Scale (GCS) to check a client for changes in the level of consciousness. The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applies. Which of the following GCS scores should the nurse document? A - E2 + V3 + M5 = 10 B - E3 + V4 +M4 = 11 C - E4 + V5 +M6 = 15 D - E2 + V2 + M4 = 8

B - E3 + V4 +M4 = 11 Rational A - The calculation is incorrect. E2 represent eye opening secondary to pain, V3 represents verbal response with words spoken inappropriately, and M5 represents motor response to pain with a local reaction. B - The score is correct. Indicating moderate head injury. E3 represents opening eyes secondary to voice stimulate, V4 represents verbal conversation that is incoherent and disoriented, and M4 represents motor response as a general withdrawal to pain. C - The score is calculated incorrectly. E4 represents eye opening spontaneously, V5 represents verbal conversation as coherent and oriented, and M6 indicated a client is able to follow commands. D - The score is calculated incorrectly. E3 represents eyes opening secondary to pain, V2 represents verbal response by the client making sounds by speaking no words, and M4 is a motor response with a general withdrawal to pain.

A nurse is collecting data from a client who has Parkinson's disease. Which of the following findings should the nurse expect? Select all A - Decreased vision B - Pill-rolling tremor of the fingers C - Shuffling gait D - Drooling E - Bilateral ankle edema F - Lack of facial expression

B - Pill-rolling tremor of the fingers C - Shuffling gait D - Drooling F - Lack of facial expression Rational A - Decreased vision is not an expected finding in a client who has PD B - The client who has PD can manifest pill-rolling tremors of the fingers due to overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult C - The client who has PD can manifest shuffling gait because of overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult. D - The client who has PD can manifest drooling because of overstimulation of the basal ganglia by acetylcholine, making the controlled movement of swallowing secretions difficult E - Bilateral ankle edema is not an expected finding in a client who has PD, but can be and verse effect of certain medications used for treatment F - The client who has PD can manifest a lack of facial expressions due to overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult.

A nurse is contributing to a plan of care for the nutritional needs of a client who has stage IV Parkinson's Disease. Which of the following actions should the nurse include in the plan of care? Select all A - Provide three large balance meals daily B - Record diet and fluid intake daily C - Document weight every other week. D - Place the client in Fowler's position to eat E - Offer nutritional supplements between meals.

B - Record diet and fluid intake daily E - Offer nutritional supplements between meals. Rational A - the nurse should provide small frequent meals during the day to maintain adequate nutrition B - The nurse should record the client's diet and fluid intake daily to monitor dietary needs and to maintain adequate nutrition and hydration. C - The nurse should document the client's weight weekly to identify weight loss and intervene to maintain the client's weight. D - The nurse should ensure that the client is sitting upright for meals rather than in a supported Fowler's position, where the client's head is elevated 45°-60° E - The nurse should offer nutritional supplements between meals to maintain the client's weight

A patient has recently been diagnosed with MS. The family asks the nurse about the common manifestations of the disease. The nurse is correct by identifying which as the most common clinical manifestation of the disease? A - Urinary incontinence B - Weakness of the limbs C - A loss of the sense of smell D - Decreased intellectual function

B - Weakness of the limbs Rational MS is a chronic inflammatory disease causing demyelination in the central nervous system, resulting in the muscles not receiving the necessary nerve impulses to function properly. There are sensory disturbances, but the sense of smell is not generally affected. Urinary incontinence may occur late in the disease. Intellectual function generally remains intact; however, late in the disease there may be some memory loss and impaired judgment.

When teaching the patient with multiple sclerosis (MS) about how to best manage his disease, the nurse determines the patient requires further instruction when making which statement? A - "It is important that I attend all of my physical therapy sessions." B - "I should eat adequate fiber to prevent constipation." C - "It is a good idea for me to take a hot shower in the morning to relax my muscles." D - "The injections of interferon beta-1b (Betaseron) will help manage my symptoms."

C - "It is a good idea for me to take a hot shower in the morning to relax my muscles." Rational Heat often exacerbates the symptoms of MS, so a hot shower in the morning is not advisable. Physical therapy and exercise are important for maintaining muscle strength. Constipation can be prevented by eating adequate fiber. Biologic response modifier drugs help treat the symptoms of MS; there is currently no cure for the disease.

Spinal Cord Injury Assessment

Continued assessment for signs of decreased oxygenation, blood pressure instability, infection, skin breakdown, gastrointestinal or nutrition problems, and urinary problems is essential.

A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching? A - "This medication will help you with your tremors." B- "This medication will help you with your bladder function." C - "This medication may cause your skin to bruise easily." D - "This medication may cause your skin to appear yellow in color."

D - "This medication may cause your skin to appear yellow in color." Rational A - Primidone and clonazepam are beta blockers given to clients who have MS to treat tremors. B - Propantheline is an anticholinergic medication that is given to clients who have MS to treat bladder dysfunction C - Prednisone is a corticosteroid medication that is given to clients who have MS to treat inflammation. An adverse effect of this medication is bruising of the skin D - Dantrolene and tizanidine are antispasmodic medications that are given to clients who have MS to treat muscle spasms. An adverse effect of this medication is a yellow appearance of the skin, also known as jaundice. The nurse should instruct the client to monitor for this finding, as this can indicate impaired liver function.

A nurse is caring for a client who has Parkinson's disease and is starting to display bradykinesia. Which of the actions should the nurse take? A - Remind the client to walk most quickly when ambulating B - Complete passive rage-of-motion exercises daily C - Place the client on a low-protein, low-calorie diet. D - Give the client extra time to perform activities

D - Give the client extra time to perform activities Rational A - The client who has PD develops a propulsive gait and tends to walk increasingly rapidly. The nurse should remind the client to stop occasionally when walking to prevent a propulsive gait and decrease the risk for falls. B - The nurse should encourage active, not passive, range-of-motion exercises to promote mobility in the client who has PD and is displaying bradykinesia C - The client who has PD often requires high-calorie, high-protein supplements between meals in order to maintain adequate weight. D - Bradykinesia is abnormally slowed movement and is seen in client who have PD. The nurse should give the client extra time to preform activities and encourage the client to remain active.

Orthostatic hypotension. Vasoconstriction is impaired after spinal cord injury, and the lack of muscle function in the legs causes pooling of blood in the lower extremities.

Deep venous thrombosis. Decreased blood pressure combined with lack of muscle movement slows venous return to the heart. Thrombosis may occur. Compression stockings, sequential compression devices, and/or heparin injections may be needed to prevent deep venous thrombosis.

Multiple Sclerosis (MS) Diagnosis

No laboratory test will definitively establish a diagnosis of MS, although most patients have elevated IgG levels in their CSF and oligoclonal bands (bands of IgG produced by electrophoresis of the CSF). An MRI study usually shows characteristic white matter lesions scattered through the spinal cord and/or brain, which confirms the diagnosis of MS. However, the clinical signs and symptoms presented by a patient usually are sufficiently characteristic of the disorder to allow the neurologist to make a diagnosis that the patient possibly or probably has MS. The clinical manifestations of the disease reflect the extent to which inflammation and scarring of the myelin have occurred

Spinal Cord Injury Complications Spinal Shock

Spinal shock is characterized by flaccid paralysis and loss of reflex activity and of sensation below the level of the injury. Spinal shock occurs immediately after injury and lasts 48 hours to several weeks.

5 stage of Parkinson's Disease

State I - Unilateral shaking or tremor of one limb Stage II - Bilateral limb involvement occurs, making walking and balance difficult. Stage III - Physical movements slow down significantly, affecting walking more Stage IV - Tremors can decrease but akinesia and rigidity make day-to-day tasks difficult Stage V - Client unable to stand or walk, is depended for all cares, and might exhibit dementia

Care of Pin Sites

Sterile technique is used and is performed according to agency policy. Solutions such as sterile normal saline are used for cleansing, and an antibiotic ointment is applied. Weights used for cervical traction must be kept hanging freely to be effective. *The halo jacket is never unfastened unless the patient is supine, because head movement will immediately occur.*Although many tasks may be delegated to CNAs or UAPs, moving or positioning patients with neurologic injury or surgery should not be delegated

Nursing Implications for Drugs Commonly Used for Parkinson Disease Med surg - Box 42-1

• Administer the drugs as close to the time ordered as possible to maintain a consistent blood level of each drug. • Pay close attention to dosage amount, because therapy is individualized to each patient. • Administer anticholinergic medications with meals to decrease gastrointestinal irritation. • Continually assess the patient for worsening of symptoms that may result from disease progression, side effects of medication, or failure of medication. • Check other medications patient is receiving for potential interactions with the antiparkinsonian drug, contraindicating administration of the drug. ****Regarding Possible Side/Adverse Effects of the Drug *Orthostatic hypotension and urinary retention *Assess patients who are taking carbidopa-levodopa for excessive or inappropriate sexual behavior. *Bromocriptine may cause changes in mental status; report observed changes. *Amantadine and pergolide may cause insomnia and should not be administered at bedtime. *Anticholinergics cause dry mouth and constipation; increase fluids to ****3000 mL/day****; treat constipation as needed per orders; add ***fiber*** to diet. *Constipation is a problem with the anticholinergic drugs; increases in dietary fiber, plenty of fluid, and exercise can help control constipation; bowel movement frequency should be monitored to prevent impaction. *Orthostatic hypotension causes dizziness and can precipitate falls; it is important for the patient to allow the blood pressure to stabilize in a sitting position before standing, to rise slowly, and to ensure balance while holding on to something when standing before walking. *Carbidopa-levodopa will turn the urine dark.

Spinal Cord Nursing Diagnosis

• Altered gas exchange due to diaphragm paralysis, diaphragm fatigue, or retained secretions. • Impaired physical mobility related to vertebral column instability, disruption of the spinal cord, and traction. • Altered cardiac output due to hypotension and decreased muscle action causing venous pooling. • Altered nutrition due to increased metabolic demand from healing injuries, slowed gastrointestinal motility, and inability to feed self. • Constipation due to lack of bowel enervation, decreased fluid intake, and immobility. • Altered urinary elimination related to decreased innervation of the bladder. • Pain due to muscle spasms. • Potential for autonomic dysreflexia due to reflex stimulation of sympathetic nervous system. • Potential for altered skin integrity due to immobility and loss of sensation. • Altered coping ability due to loss of control over bodily functions and altered lifestyle secondary to paralysis. • Altered body image due to paralysis and loss of control over bodily functions. • Altered family function due to change in role within the family because of neurologic deficits. • Grief due to neurologic deficits and to changes in roles and lifestyle. Specific NANDA-I diagnoses can be chosen from the NANDA-I list (see inside back cover).

Multiple Sclerosis (MS) Signs and Symptoms

• Motor dysfunction can include weakness or paralysis of limbs, trunk, and neck; diplopia caused by oculomotor weakness; and spasticity of the muscles. • Sensory dysfunction may include numbness, tingling, burning, and painful sensations; patchy or total blindness or blurring of vision in one or both eyes; dizziness; ringing in the ears; and hearing loss. • Problems of coordination include ataxia (unsteady gait), intention tremor of limbs and eyes, slurring of speech, and dysphagia (difficulty swallowing). • Mental changes usually are limited to depression and cognitive problems such as impaired judgment, decreased ability to solve problems, and memory loss, which occur late in the disease. • Fatigue is a characteristic of MS and often is worsened by heat (e.g., a hot shower, hot weather, or high humidity may induce or worsen symptoms).

Parkinson's Disease (PD) Patient Teaching Med Surg (559)

• Using adjustable tables may help reduce arm fatigue and increase comfort by providing increased support and stabilizing the arms. • Household chores such as folding laundry may provide gentle exercise. • Music can provide relaxation, or motivation for exercise. • Sit upright when eating. • Close your lips and keep your chin up. • Use a straw when drinking to strengthen the muscles of the lips, mouth, and throat. • Use big strokes when writing and use lined paper. • Use a larger pen or marker and change writing position often. • Change positions slowly. • When turning around, do not pivot. Move forward and slowly walk in a circle. • Avoid moving quickly. • Avoid moving in a backward direction.