Med/Surg Test #3
Convergence
- Ability to turn both eyes inward towards the nose at the same time
How is sound conducted?
- Air conduction and Bone conduction - Air is more sensitive than bone
Validation Therapy
- For later stages of the disease - This allows the staff to recognize and acknowledge the pts feelings - i.e. If the pt had breakfast already in the morning, but states that they haven't, do not tell them that they have already eaten, tell them that you will get them a cracker or some toast (something light since they won't eat it because they've already had breakfast)
Keratoplasty
- For permanent damage to cornea - Corneal transplant replaced from a human donor (cadaver) - Nerves are anesthesized so pt cannot move or see out of the eye - Tool removes diseased cornea and then removed donor cornea so that it is a perfect fit. Donor cornea is sutured into eye - Outpt procedure
IVIG
- Given IV and it distracts the WBC so instead of attacking the myelin sheath, they attack the immunoglobulin
Acute Back Bain
- usually results from trauma or injury - Damage usually occurs via flexion, extension, hyperflexion, and/or hyperextension
Dx Tests for the Ear
-Cultures for infection - CT (esp for tumors) - MRI (soft tissue damage)
Prevention of Back Pain Pg 886, Chart 43-2
- Good posture - Exercise - OSHA demands that all companies have a plan to min musculoskeletal injuries - ERGONOMICS!! ---Correct positioning and movement to min injury ---Body mechanics and cieling lift in RN
Dry Age related MD
- Gradual blockage of retinal capillaries, allowing the retinal cells in the macula to become ischemic and necrotic - Can also be caused by the growth of new blood vessels in the macula - MORE COMMON - Progresses at a faster rate
Eyes/Pupils
-Do the eyes open spontaneously? -What is the size of the pupils? -Can the patient see you? -Does the patient follow you with their eyes? -Does the patient have blurry vision? -Do you need a penlight?
S/S of Primary open-angle glaucoma
- Gradual vision loss - Gradual loss of visual field (PERIPHERAL VISION loss) - Mild eye aching - Headaches - Possible damage to optic nerve fn - Seeing halos around lights - Decreased visual sensory perception NOT improved with specs
Tx of MG Pg 921, Chart 44-4
*Airway, Swallowing, Risk for injury* -Plasmapheresis - antibodies removed from plasma ----S&S of complications - hypovolemia ----Care of AVF -Respiratory support ----ABG ----PFT ----BIPAP ----AMBU and suction @ bedside - Mobility ----PT OT ----Assist w/ positioning to prevent ulcers (pressure ulcer reducing devices) -Promoting self-care guidelines ----Impaired ADLs / rest ----Plan activities after med administration ----Allow for rest to prevent a crisis -Assisting with communication ----SLP - book / word boards/ lip read/ simple questions -Nutritional support (Chart 44-4) ----Chewing/swallowing exercise/calorie count ----Give them extra time ----Small Bites ----Meds on time because it helps with salivation -Eye protection ----Corneal abrasion / artificial tears/eye patch 1 at a time -Surgical management ----Usually involving thymectomy ----Post op complications= Respiratory priority
Level Of Consciousness
*Change in LOC is reliable indication that neuro fn has declined -Alert -Confused (Don't know name, place, etc, but otherwise functional) -Lethargic (Sleepy) -Obtunded or Stuporous (Respond only to some things, most commonly only pain -Comatose (unresponsive)
Guillain-Barré Syndrome (GBS)
- ACUTE rapidly progressive inflammation of the peripheral sensory and motor nerve - Autoimmune - 30-50 onset -Demyelination of peripheral nerves where the immune system starts to destroy the myelin sheath that surrounds the axons of the peripheral nerves or attacks the axons themselves - Most patients recover months to 1 year 20-25% left with residual disability
S/S of ALS Pg 910, Chart 43-15
*Depend on location of affected neurons* - "Trapped in their body" i.e. if they have an itch they can feel it, but cannot communicate or move their arm to relieve it -PROGRESSIVE weakness, muscle wasting, spasticity, paralysis - No motor coordination -Fatigue, muscle weakness, cramps, twitching, incoordination -Difficulty talking, swallowing & breathing -Weakness & atrophy of arms, trunk or legs -Bowel and bladder function usually NOT interrupted -Cognitive function impaired-some patients -Death caused by COMPLICATIONS i.e. infection, respiratory failure & aspiration
S/S of HD
*Distinct features are 1) Progressive mental status changes, dementia, & 2) Choreiform movements (rapid / jerky movements) in the limbs, trunk & face* MOVEMENT S/S: -Involuntary jerking or writhing movements (chorea) -Muscle problems, such as rigidity or muscle contracture (dystonia) -Slow or abnormal eye movements -Impaired gait, posture and balance -Difficulty with the physical production of speech or swallowing -Bowel and bladder incontinence COGNITIVE S/S: -Difficulty organizing, prioritizing or focusing on tasks -Lack of flexibility or the tendency to get stuck on a thought, behavior or action (perseveration) -Lack of impulse control that can result in outbursts, acting without thinking and sexual promiscuity -Lack of awareness of one's own behaviors and abilities -Slowness in processing thoughts or ''finding'' words -Difficulty in learning new information - Decreased attention span, memory loss PSYCHIATRIC -Most COMMON is Depression -Feelings of irritability, sadness or apathy -Social withdrawal -Insomnia -Fatigue and loss of energy -Frequent thoughts of death, dying or suicide -Obsessive-compulsive disorder, a condition marked by recurrent, intrusive thoughts and repetitive behaviors -Mania, which can cause elevated mood, overactivity, impulsive behavior and inflated self-esteem -Bipolar disorder, or alternating episodes of depression and mania
EXAM: Meds for MS (Names of more meds, Pg 908 of book)
*Drug therapy aimed at relapsing MS* -EXAM: Interferon - Avonex -EXAM: Glatiramer - Copaxone ---*These are immunosuppresive drugs* -Natalizumab - Tysabri [high risk for anaphylaxis, high risk for opportunistic infections, damage liver TEACHING -Rotate sites / reactions are common - Avoid crowds - S&S of infection
Meds for Parkinson
*Drugs that increase dopamine and increase impulse movement* -Dopamine agonists- Levodopa or Sinemet (Carbidopa-Levoopa) (extended release tablets available) ---Improve mobility and rigidity ---Causes darker urine ---Take weeks to months to take effect ---SE: hypotension, constipation , long term use of sinemet = dyskinesia - inability to perform voluntary movements. Give before meals to increase absorption in blood brain barrier -Catechol O- methyltransferases (COMTs): Inactivate dopamine [Comtan] - inhibitors prevent inactivation and prolong action of levodopa. Not beneficial for those who need specific doses -Monamine Oxidase type B (MAOIs) inhibitors - decrease freezing episodes. ---Drug toxicity interventions - evidenced by delirium, cognitive impairment, hallucinations ---Avoid food with tyramine i.e. cheese and aged, smoke, cured foods and sausage, No red wine ---Reduce dose/change medication/DRUG HOLIDAY -Antiviral (Amantadine): imporves ACH - Anticholinergics: For severe motor S/S, avoid in elderly
RN Care
*PT, OT, SLP, Dietician Collab!!* *Supportive to all the body systems* - Check CN V, VII, X, XI, and XII - Plamapharesis or IVIG -Respiratory and Cardiac care ---Airway patency, aspiration percaution, HOB 45 degrees, chest physiotherapy PRN, O2, Assess respiratory frequently, If LOC changes report, ABGs, PE, DVT -Mobility: ----Move pt Q2h ----Encourage max independance ----Active or passive ROM ---Wt pt 3x/week -Pain management ---Neurontin / tricyclic antidepressants -Communication ---SLP collab- use simple communication i.e. blink or move finger for yes, communication board, phone, computer. ---Describe and explain in detail what you are doing -Nutritional - malnutrition -Involvement of family, other team members - PT/OT -Education- ambulation, ROM MEDS: - Stool softners - Steroids - Pain meds
Interventions for Back Pain (Surgical) Pg 889, Chart 43-4
*Position for spinal surgery is PRONE TRANDELENBURG* PREOP - Informed Consent - Teachings about post op i.e. graft may be used if spinal fusion done, proper brace care and positioning while brace off, how to get OOB and move in bed, Restrictions, and report S/S i.e. tingling OPERATIVE Minimally Invasive Surgery - Microscopic (or Surgical) Endiscopic Diskectomy (MED) or Percutaneous Endoscopic Diskectomy (PED) - Microdiskectomy Laser-assisted Laparoscopic Lumbar Diskectomy Conventional Open Procedures - Diskectomy - Laminectomy - Spinal Fusion POST OP CARE - MIS pts go home same day, complications are rare - Open Procedures ---Common complications (look at Chart 43-4) ---Neuro and VS often ---Clear drainage, headache, and bulging can indicate CSF leak--Report ASAP ---LOG ROLLING: correct turning for the pt where you move the pt as 1 unit and do this Q2h
Bacterial
- "Pink Eye" S/S: - Blood vessel dilation - Edema - Tears - Discharge TX: - Culture of drainage - Antibiotic drops - Wash hands - Do not touch unaffected eye unless hands washed - Avoid sharing washclothes and towels - CL worn during infection need to be thrown out
How many hemispheres and lobes does the brain have?
- 2 hemispheres ---Right controls right and left controls left - 4 lobes
Multiple Sclerosis
- A disease of the CNS -Idiopathic -Chronic auto-immune disease that affects the MYELIN SHEATH & conduction of the central nervous system -Chronic with periods of remission / exacerbation - Inflammatory response in the white matter of the CNS -Myelin sheath is DEMYELINATED resulting in an interruption of impulses between the brain and spinal cord, & body - Life expectancy normal as long as effects of disease are tx
Corneal Abrasion
- A scrape or scratch injury to the cornea - Very PAINFUL - Caused by small foreign body, trauma, CL, malnutrition, dry eye syndrome, and some cancer therapy - This allows organisms to enter the eye and LEADS TO corneal infection
External Otitis
- Allergic response or inflammation that occurs to the outer ear when it comes into contact with irrigation or infective agents, or allergic agent (i.e. hairspray, ear phones, etc) - Infectious or noninfectious - Most often in hot, humid environment and over the summer is common aka SWIMMERS EAR -NECROTIZING OR MALIGNANT OTITIS can spread to the ear and brain and cause death S/S: - Redness - Tenderness - Swelling of ear canal (can cause temp hearing problem) -Drainage is usually white/green TX: - Gtts of antibiotics, steroids, analgesics PO - Heat to the ear for 20 mins TID - Min head movements - If edema occludes the canal, use an EARWICK (a long piece of guaze inserted past the blockage) and apply meds to the external end. - PROPHYLAXIS: Sol of 50% rubbing alcohol, 25% white vinegar, and 25% distilled water
Conjunctivitis
- Allergies - Bacterial
Caution with CT w/ Contrast Pg 845, Chart 41-4
- Allergies - Kidney fn *Drink a lot of H2O after*
Huntington's Disease (HD)
- An inherited disease that causes the progressive breakdown (degeneration) of nerve cells in the brain. - Has a broad impact on a person's functional abilities and usually results in movement, thinking (cognitive) and psychiatric disorders. - Onset usually 30-50 y/o -Excessive amounts of dopamine in cortex/ decreased amount of GABA (inhibitor neurotransmitter)
Focused Assessment for a pt w/ Hearing Loss Pg 1010, Chart 48-7
- At first they especially cannot hear high frequency consonants i.e. S, Sh, f, th, and ch
Preventative Methods for Hearing Loss
- Avoid q-tips, bobby pins, etc to clean ears - Use protective ear devices with loud noises - Earplugs with swimming - Swim- Ear to assist with drying ears post swimming
Interventions for Back Pain (Nonsurgical) Pg 887, Chart 43-3
- Back pain <3 mos is self limiting - >3 mos is chronic ACUTE LOW BACK PAIN - Williams Position: pt is semi-fowlers with a pillow under the knees to keep them flexed OR sits in reclining chair - Shoe insoles or floor pads for prolonged standing - Do not sit for prolonged time - NSAID's/ Opioids - Steroids CHRONIC LOW BACK PAIN - NSAID's, Opioids, and Antidepressants - Heat/ Cold compresses ----Heat applied for 20-30 mins 4x/day ----Hot/Cold showers - PT: Provide deep heat therapy i.e. US tx and diathermy ---Phonophoresis (topical agent) applied and then continuous US done ----Iontophoresis: Small electrical current and dexamethasone used ---Exercise Program -Wt Reduction ALTERNATIVE THERAPY - Chiropractic or Spinal Manipulation - Acupuncture - Relax techniques
Corneal Infection
- Bacterial, protozoal, and fungal infections can LEAD TO corneal ulceration
Assessment
- Basic assessments of inspection, asking questions, getting hx, etc. ----Hx of down syndrome or osteogenesis imperfecta can cause deafness - TEACH pts that they should not clean their ears with anything smaller than the tip of their finger - TEACH how to properly remove cerumen - Assess for ototoxic drugs - Ask if they have any current S/S ----Hyperacusis: intolerance for sounds that do not bother others ---Tinnitus: ringing of the ears ---Vertigo: Dizziness - Ear should be attached to the head at a posterior angle of 10 degrees or less - Person w/ Gout may have Tophi (painless nodules) on their pinna
Minor Eye Conditions *Pictures of conditions will be on the test*
- Blepharitis ---Inflamed, itchy, red ---Greasy scales on brows and lids -Entropion (Previous chpt has info) ---Inward turning of lid; lashes rub against eye ---Surgical correction required -Ectropion (Previous chpt has info) ---Outward turning of lid ---Surgical correction required -Hordeolum ---Internal or external stye ---Warm compress 4x/day and antibacterial ointment (apply compress and ointment) -Chalazion ---Inflammation of sebaceous gland in eye ---Painless swelling ---Warm compress 4x/day and antibacterial ointment (apply compress and ointment)
Retinal Hole
- Break in the retinal - Retinal hole can lead to an infection, which can lead to infection of the brain - Implement strict HYGIENE - TX: Closed or Sealed via scar formation that binds the retina and choroid together around the break, Cryopexy: When laser photocoagulation and a freezing probe are used to do this
Hard Cervical Collar
- Called Miami J or Philadelphia - Daily inspection of the skin under the collar necessary - Padding is placed at the pressure points to prevent skin breakdown
Peripheral Nerve Trauma
- Can be Partial or complete severance, contusion, stretching,, constriction, or compression, ischemia, electrical, thermal, or radiation -Degeneration or retraction of nerve distal to injury within 24 hr
Exudative MD
- Can occur at ANY AGE - Newly formed blood vessels invade surrounding area and cause scar formation and visual distortion OR can occur from a sudden detachment of the pigment epithelium in the macula
External structures
- Canthus - Conjunctivae - Lacrimal gland - Punctum (opening on the nasal side of the lid edges)
Cerumen or Foreign bodies
- Cerumen is most common cause of an impacted canal. S/S: -Feeling of fullness in the ear - Pain - Can't hear well - Itching - Dizziness - Bleeding - Object may be visible TX: -Use of ceruminolytic agents or mineral oil to soften hard cerumen OR add 3 gtts of oil at HS and 3 gtts of Peroxide TID - Irrigation ---Low pressure irrigation with H2O and hydrogen peroxide (warm to body temp) ---May take more than one sitting ---MAX 50-70mL in one sitting ---STREAM of H2O is aimed above or below the impaction -Discourage use of Qtips - If an insect, use a flashlight or suffocate with mineral oil and then remove - Surgical removal also option
EXAM: Trachoma
- Chronic, bilateral scarring form of conjunctivitis -Caused by Chlamydia trachomatis -Chief cause of preventable blindness -Infection control - TX is antibiotics - TEACHING the same as conjunctivitis PLUS tx STD to prevent this!
Otoscope Assessment
- Looks at external canal, cerumen in the canal, lesions, and whether or not the tympanic membrane is intact - Tilt the pts head, hold the otoscope up side down in dominant hand, and gently pull the pinna UP AND BACK -Insert the speculum into ear canal and then look to prevent damage
Tx of MS
- Cognitive Impairment (place single date calendar, tell them to leave written/ voice messages for themselves, frequently used item in familiar places) -Mental Health counseling ---Depression -Sexual dysfunction (viagra or EROS clitoral therapy device) -Promoting mobility (Rehab, multiidisciplinary, Exercise program) -Bladder dysfunction -Dysarthia (SLP) -Diplopia (Eye Patch alternated from eye to eye for a few hrs) -Immunosuprressive therapy ----Cyclophosphamide (Cytoxan) - stabilze the disease process ----Solu-Medrol - decrease inflammation
General Care for a pt w/ Alzheimer's will include:
- Cognitive stimulation and memory training - Structuring the environment - Orientation and validation therapy - Promoting self mgmt - Promoting bowel and bladder continence - Promoting communication
Rigidity Classifications
- Cogwheel (rhythmic interruption of muscle movement) - Plastic (mildly restricted) - Lead Pipe (total resistance to movement)
Halo Fixator
- Commonly used for cervical spine stabilization - Static traction device with 4 pins that are inserted into the skull - metal halo ring is attached to the plastic vest or cast RN DUTIES - Never move or turn pt from the halo - Make sure jacket has one finger of space - Neuro status - Keep special wrench taped to the vest in case the vest must be removed for CPR - Do not use sharp objects to scratch under the vest - Pin site care according to hospital i.e. saline - Vaseline dressings - VS and monitor S/S infection (REPORT changes ASAP) COMPLICATIONS - Loosening of the pin - Local infection - Scarring - Osteomyelitis - Subdural abscess - Instability
CONJUNCTIVAL DISORDERS
- Conjunctivitis - Conjunctival Hemorrhage -Trachoma
Intraocular Pressure
- Controlled by the vitreous humor - The vitreous humor must be shaped like a ball or else it affects pressure - Too low: eyeball becomes soft and collapses - Too high: The pressure compresses the capillaries in the eye as well as nerve fibers
CORNEAL DISORDERS
- Corneal Abrasion, Ulceration, and Infection - Keratoconus and Corneal Opacities - Cataract
Surgeries
- Corneal Ring replacement (for misshaped cornea still clear--flexible ring placed to change shape of cornea) - Keratoplasty
Ear Irrigation Pg 1005, Chart 48-4
- DO NOT irrigate with eardrum perforation or otitis media (spread infection) - DO NOT irrigate if object is visible- this must be manually removed -Tilt head toward side of affected ear - direct stream of fluid against sides of canal -Instruct patient to lie on affected side to facilitate drainage -Contraindicated if there is evidence of swelling/tenderness
Dopamine Involvement
- Decrease in amt of Dopamine (person loses ability to refine movements)
Corneal Ulceration
- Deeper injury -EMERGENCY! Because cornea does not have a separate blood supply and permanent eye damage can occur rapidly - Homemade CL sol and large containers of CL sol have increased risk of getting this due to contamination
Spondylosis
- Defect in a vertebrae usually lumbar
Keratoconus
- Degeneration of the corneal tissue resulting from abnormal corneal shape (from trauma or inherited) - Requires surgical tx
Community Based Care
- Depends on Residual affects and is individualized based on fn - Oral and written instructions given - Self help and support groups info
Anisocoria
- Difference in size of pupils (can be normal for some people)
CNS: Spinal Cord
- Divided into 4 areas - C1-C7: Neck - T1-T12 - L1-L5 - Sacral S1-S4
Teachings R/T Corneal Abrasion, Ulceration, and Infection
- Do not use drug on unaffected eye - Wash hands before touching affected eye and again before touching unaffected eye - Discard open CL sol and used CLs - If two eye affected, use separate gtts for each eye and label it OD OS - DO NOT wear cls until completely healed - Return for FU visits - Apply drugs as rx even at night!
Maximizing Communication w/ person w/ Hearing loss Pg 1014 Chart 48-10
- Don't Shout - Talk slow and clear - Use normal, low tone - Hand gestures - Write things down - Point at Pictures - Lip Reading - Sign Language
Reality Orientation
- Done in early onset of the disease - Clocks and single date calender's in room - Frequently orient pt to date, time, location, and who they are
Ptosis
- Drooping
Types of MD
- Dry Age related MD - Exudative MD (Wet AMD)
Allergies
- Edema, Sensation of burning - Bloodshot eye -Excessive tears -Itching TX: - Vasoconstrictor - Steroid drops
S/S MG Pg 918, Chart 44-3
- Fatigue / weakness (esp upon exertion- usually relieved with rest) -Ptosis - unilateral drooping eyelids (EXAM) -Diplopia (EXAM) -Dysphagia (EXAM)- High risk for aspiration - Respiratory Distress - Bowel and bladder incontinence - Bulbar movements (facial expression, chewing, and speech are affected) - Neck and shoulder weakness - Muscle atrophy - Eaton Lambert Syndrome (small cell carcinoma of the lung, muscles of the trunk, pelvic, and shoulder)
Corneal Staining
- Fluroescein or other topical dyes to see irregularites of cornea - Good for CORNEAL TRAUMA, CL problems, -NON-INTACT AREAS SHOW UP GREEN
Mental Exams that Can be performed to test Cognitive fn
- Folstein's Mini Mental State Examination ---Scored from 0-30 ---Advanced Alzheimer will have below 5 - Set Test ---Asked to name 10 items in each of the 4 categories of fruits, animals, colors, and towns (FACT) - Short Blessed Test ---In acute care settings - Brief Interview for Mental Status ---Long tern care facilities
Causes of Encephalitis
- HSV (EXAM) Viral is the big problem here!! -Measles -Mumps -Polio -Rabies -Rubella -Varicella (chickenpox) - Varicella Zoster -Adenovirus -Coxsackievirus -Cytomegalovirus -Eastern Equine Encephalitis Virus -Echovirus -Arbovirus (mosquitos or ticks) - West Nile virus - Acanthamoeba (one that enters the brain via nose) -An allergic reaction to vaccinations -Autoimmune disease -Bacteria, such as Lyme disease, syphilis, and tuberculosis -Parasites such as roundworms, cysticercosis, and toxoplasmosis in AIDS patients and other people who have a weakened immune system -The effects of cancer
Spinal Immobilization and Stabilization
- Hard Cervical Collar - Halo Fixator
Hearing Aid Care Pg 1011, Chart 48-8
- Hearing Aids vary from small to big in size - Do Not Loose Hearing Aids---$$$
Presbycusis
- Hearing loss that occurs with old age - Degeneration of the cochlear nerve cells, loss of elasticity, or a decreased blood supply are the causes - Deficiencies of Vit B12 are risk factors for this - Other co-morbidity can also increase the risk
Herniated Nucleus Pulposus (HNP)
- Herniated disc that can press down on the adjacent spinal nerve (sciatic most common) and cause severe burning or stabbing pain down the leg and foot - Most common in L4 and L5 S/S: - Pain - Muscle spasm - Paresthesia - Leg weakness - Bowel and Bladder incontinence
Problems with refraction
- Hyperopia: Far sighted (does not refract enough) - Myopia: Near sighted (over bends light) - Astigmatism "blurred vision"- unevenly cureved surfaces distort vision - Presbyopia: R/T OLD age
Myasthenia gravis
- Idiopathic -CHRONIC, PROGRESSIVE disease characterized by remissions and exacerbations (insidious/slow) -Acquired autoimmune disease -Remissions / flare-ups -MG is attack of the ACH receptors (affects transmissions) ---Nerve impulses are not transmitted [muscles cannot contract] - Hyperplasia of the thymus and thyoma occur
Pupillary Constriction and Dilation
- If light enters one or both eyes, then BOTH eyes constrict - Pupillary constriction= MIOSIS - Pupillary Dilation= MIDRIASIS
TX
- Immobilization - Surgery (may delay surgery for 3-8 weeks or do it right away w/ laser) --Nerve graft may be need ---Arm is placed in an exaggerated flexion in a cast to compensate for the shortening -Rehabilitation through physiotherapy -Skin care -PT & OT
Causative factors
- Immune-mediated ---IgM attacks myelin sheath of peripheral nerve and nerves are damaged and impulses are not transmitted like they should - Bacteria - Influenza -Some Vaccines - Surgery, trauma, pregnancy
Perichondritis
- Infection of the fibrous tissue that surrounds the cartilage and shapes the pinna. - If blood supply is affected to the cartilage, necrosis can occur and deform the pinna. -Causes: ear piercing, insect bites, trauma -Incision and Drainage and IV antibiotics may be needed
EXAM: Mastoiditis Patient teaching (Post-op care: Chart 48-6, p 1007)
- Infection of the mastoid bone air cells due to untreated otitis media - CT Scan shows fluid in air cells of mastoid process S/S: - Cellulitis- infections spread -Pain- unrelieved by a myringotomy -Low grade fever -Ear is pushed sideways and down -Red, thick, immobile ear drum w/ or w/out perforation -Lymph nodes are tender and enlarged -Hearing loss -Ear drainage and loss of appetite - Fever & chills - Hearing loss -Headache & dizziness -Drainage -Pain & tenderness -Stiff neck, facial paralysis -Vomiting -Can cause meningitis TX: -Cultures of ear drainage -Infection control (equipment- avoid cross contamination) -Medications- IV antibiotics, pain management, comfort measures -Mastoidectomy with tympanoplasty (to reconstruct the ossicles) -Surgical removal of fluid with a needle - Grommet (tube) - Debridement EXAM: COMPLICATIONS: -Cranial nerve VI & VII damage (Facial nerve injury/paralysis and pt cannot look sideways) - Meningitis (Most Common) - Continued Infection - Vertigo - Brain abscess
Encephalitis
- Inflammation of brain tissue - Virus travels to the CNS via bloodstream, along the peripheral or cranial nerve or in the meninges - Demyelination = hemorrhage, edema, cell death and necrosis [cerebrum, brainstem, cerebellum] - The virus causes inflammation of brain tissue. The brain tissue swells (cerebral edema), which may destroy nerve cells, cause bleeding in the brain (intracerebral hemorrhage), and brain damage. - EXAM: Encephalitis caused by the herpes simplex virus is the leading cause of more severe cases in all ages, including newborns. -A number of viruses for which there is now a vaccine may also cause encephalitis. These include: --Measles --Mumps --Polio --Rabies --Rubella --Varicella (chickenpox)
What is the triad that marks HD?
- Inheritied dominant trait - Choreoathetosis - Dementia
Post Op Anterior Cervical Diskectomy Care Pg 892, Chart 43-6
- Initial brace work for 4-6 weeks and then a soft color for several weeks after that
Assessment of Back Pain
- Insepction - pt complaints - Paresthesia - Urinary and fecal incontinence - Sciatic nerve compression MORE SERIOUS: -Fever and chills - Recurrent UTI - Recurrent skin infections - Progressive motor and sensory loss - Difficulty urinating and having bowel movement
Glasgow Coma Scale (Picture Printed Out)
- Know how to grade a person based on their S/S - <7 comatose, but post op is expected to be <7 and they are not considered comatose - A decrease of 2 or more points is significant-- tell DR Also communicate w/ dr new findings of abnormal flexion or extension, pinpoint, dilated, and nonreactive pupils, change in LOC ---Change in LOC is earliest S/S of a neuro problem
Drug Holiday
- Lasts typically up to 10 days - Stop the meds for a period of time because of toxicity S/S - When the drugs are at the highest dosage and are not effective, this is used - If a drug holiday is needed, then it indicates that the pts condition is poor
Steps that an image is processed through the eye
- Light enters through the lens and travels all the way back to the retina - The reflection of light is then interpreted by the retina and to the optic nerve where it is then interpreted by the brain *Through cornea, aqueous humor, lens, vitreous humor, then to the retina*
Dementia
- Loss of brain fn that is chronic and progressive - Alzheimer Disease is most common type ---Progressive, irreversible deterioration of intellectual functioning ---Prognosis—4-6 years following diagnosis - Vascular dementia next common
Slit lamp
- Magnifies anterior structures
Accomodation
- Maintaining clear vision when the gaze is shifted from distant to near object
Ocular Melanoma
- Malignant eye tumor that can easily metastasized to brain - UV light exposure usually causes this - S/S: increased IOP, vision decreased - Dx: MRI and Ultrasound - TX: Enucleation, Radiation (a radioactive plaque is placed and left in for rx amt of time usually 3-6 days), Cyloplegic (paralyzing) drops and steroid combo used, and Eye patch may be used - Complications of radiation: Vascular, retinopathy, glaucoma, necrosis of sclera, cataract, vitreous hemorrhage
Tonometry
- Measures IOP - Instrument applies pressure to the outside of the eye until it is equal to to the inside of the eye - NORMAL RANGE IS 10-21 - Necessary for all who are >40 y/o
Dx of Dementia requires 2 or more problems with
- Memory - Communication and language - Attention span or ability to focus and pay attention - Reasoning and judgment - Visual perception
Imaging/ Dx
- Mild nonspecific back pain not usually imaged - Severe or progressive motor or sensory loss is imaged - X ray (flexion-extension views) - MRI - CT - Electro-diagnostic testing i.e. Elctromyography (EMG) ---Determine neuropathies or radiculopathies
Retinal Tear
- More jagged, irregularly shaped break in the retina - TX: Closed or Sealed via scar formation that binds the retina and choroid together around the break, Cryopexy: When laser photocoagulation and a freezing probe are used to do this
Ear drum Appearance
- NORMAL: shiny, transparent, opaque, pearly gray, without lesions - OTITIS MEDIA: redness on the membrane, bulging
Spinal Stenosis
- Narrowing of spinal canal, nerve roots, or intervertebral formina - >50 common - Caused by infection, trauma, herniated disc, arthritis, disc degeneration
Causes of Alzheimer's Pg 873, Table 42-4
- Neuritic plaques
Parkinson's Disease
- Neurodegenerative disease - Primary parkinson is IDIOPATHIC - Secondary parkinson is from other conditions i.e. psych meds, brain tumors - TWO MAJOR neurotransmitters involved are: DOPAMINE and ACH
What type of pt do you NOT use the otoscope for?
- Never use on a confused pt or pt who is unable to hold head still during an examination
Tx for any MD
- No Cure - Slow progression - Reduce risk factors ---Long term DIET of Vit B12, Carotenoids LUTEIN and ZEAXANTHIN -PT SAFETY AND COMFORT!! --- Orient pt, room free of clutter, call bell in reach ---Where do you place food or talk to the pt w/ MD? To the R or L since they have no central vision WET MD -Laser Therapy (seal leaking blood vessels) - Vascular Endothelial Growth Factor Inhibitors (VEGFI): Ocular injections
Interventions
- No cure - Psychosocial support resources, psychotherapy, speech, physical, occupational therapies -Genetic counseling -Speech therapy (SLP) -Dietitian -PT/OT - Home Health Aids/ RN -Social worker -Meds: Medications for movement and psychiatric disorders
Dx Testing for Alzheimer's
- No definitive testing--just rule out other causes with a complete work up - Genetic testing available but is not a predictive test
Risk Factors for developing Back Pain Pg 886, Chart 43-1
- Obesity - Smoking - Congenital i.e. scoliosis - Petite, Euro American women
Interventions for Corneal Abrasion, Ulceration, and Infection
- Obtain a culture of the cornea or ulceration - Fluorescein stain (damaged areas appear green) - Corneal scrapings- cornea is anesthetized first - TX: Antibacterial, antifungal, antivirals, steroids (Can be given as gtts, injected subconjunctivally, or injected via IV) ----Drops are usually Q hourly for the 1st 24h
Lower Back Pain (Lumbosacral Back Pain)
- Occurs in lumbosacral area CAUSES - Muscle strain, spasm, disc degeneration, or herniation - Spondylosis - Spondylolisthesis - Spinal stenosis - Age
Types of MG
- Ocular - Generalized
S/S of Meningitis Pg 864 Chart 42-8
- Ottorhea and Rhinorrhea that is leaking CSF - NUCHAL RIGIDITY - Photophobia - Phonophobia - Headache - Myalgia - Nausea and Vomiting - Confusion - Decreased LOC - Maculopapular Rash: Enterovirus - Petechial Rash: Meningicoccal - Positive Kernigs and Brudzinskis signs - Increased ICP - Seizure Activity - Syndrome of Inappropriate Antidiuretic Hormone - Water Retention - Coagulopathy - Thrombi
S/S of Corneal Abrasion, Ulceration, and Infection
- Pain - Reduced Vision - Eye secretions i.e. cloudy or purulent fluid - Cornea may look hazy
Perceptive /Sensorineural loss
- Permanent damage- will need hearing aid CAUSES -Congenital - maternal exposure to certain communicable diseases -Infection - Drug toxicity -Trauma - Prolonged exposure to loud noise -Labyrinth disease - Meniere's disease COMPLICATIONS -Vertigo -Tinnitus -Vomiting TX -Medication -Surgery -Combined loss if conductive and sensorineural -Psychogenic loss- functional
Reflex
- Positive Babinski is a bad thing
Areas of the brain affected by Alzheimers
- Precental gyrus of the frontal lobe - Superior temporal gyrus - Hippocampus - Substantia nigra
Risk Factors for developing MG
- Previous autoimmune disorder - Stress - Hormonal changes i.e. pregnancy, thyroid problems - Exposure to extreme temps - Excessive exercise
Phacoemulsification
- Probe is inserted and uses high frequency sound waves to break up lens to small pieces which is then removed via suction
Teachings R/T eyes
- Protection methods for UV light exposure, when working w/ particulate matter, sluid or blood splatter, high temps, or sparks - Avoid rubbing eyes to prevent trauma - Wash hands before touching lids - Proper eye drop instillation technique - Control DM and Htn - Yearly evaluation (young adults w/ NO vision problems Q3-5yrs) - See dr immediately for eye injury or infection, decreased sensory perception, sudden ocular pain
Exophthalmos
- Protrusion of the eye
Dx of Parkinson
- Pt starts off writing big and then gets smaller and more illegible towards the end
Enucleation
- Removal of eyeball - use NS to clean *How else to take care of fake eye?*
Preventing Injuries and mgmt of a Wandering Pt Pg 878, Chart 42-15
- Restraints as VERY LAST resort---it confuses pt more -Safe Return Program- program to find lost dementia people-- GPS can be instilled in shoes, bracelets, etc - Frequent walks - Keep pt busy w/ structured activities i.e. puzzles - Remove dangerous items from pt - IV's and other tubing should be avoided if possible, if needed, place in a place where pt cannot easily see it - Keep pts hands busy i.e. have them hold stuffed anmal
Home Care for MS
- SAFETY! - Rehab (PT) - Avoid overexertion, extreme temps, humidity, and people with infection - Teach about meds - Conversation strategies to conserve energy
Community Based Care
- SAFETY! - Teach when to take meds and give written instruction - Teach how to prevent infection post op
RN interventions w/ pt w/ cataracts
- SAFETY!!
Changes that occur with AGE Pg. 970 Chart 46-1
- STRUCTURAL Changes ----Ectropion (lower lid relaxes and falls away from eye) ----ACRUS SENILIS (opaque, blue/white ring around the eye) ----Clarity and shape of cornea ----Sclera yellows due to fatty deposits ----Decreased eye muscle tone ----Dry eye ----Corneal changes (cataracts) ----Less ability to dilate pupil ----More light needed for reading - FUNCTIONAL Changes ----Lens hardens, loses elasticity ----Near point vision increases, far point vision decreases and pt has PRESBYOPIA ----Accommodation gradually lost ----Color perception decreases ----IOP increases
EXAM: Retinal Detachment
- Separation of he retina from the epithelium -Initial phase, detachment is partial (curtain S/S occurs) - In opthalmoscope it shows gray bulges or folds in the retina CAUSES: -Trauma -Aging -DM -Tumors S/S: -Flashes of light (Photopsia) -Floaters -Loss of vision -Curtain sensation -NO PAIN - Floating dark spots TX: -Sedatives & tranquillizers -Surgery (Scleral Buckling) ---An indentation is formed outside of the sclera, holding it in place ---Gas or silicone oil may be placed via injection into the eye to promote retinal reattachment EXAM: POST OP RN MGMT -Bed Rest - No bending forward -Place patch on 1 or both eyes to decrease movement - Eye shield in place -Place in dependent position-- Pt to be in PRONE position -Avoid bumping head, & washing hair - Avoid reading or close activities for a week -Avoid strenuous activity for 3 months - Avoid activities that increase IOP - TEACH pt: report increase in pain, infection, S/S of detachment i.e. reduced vision, pupil that doesn't constrict, etc.
Complications of Cataract Surgery
- Sharp sudden pain - Bleeding -Increased discharge - Green. yellow, thick discharge - Lid swelling - Reappearance of bloodshot after the it was already white - Decreased vision - Flashes of light - Floaters
Corneal assessmnet
- Shine light from the side and should be transparent, smooth, shiny, bright
RN Care
- Slow process - Control emotional outbursts - Support (patient and caregiver) -SAFETY (prevent injury) #1\ - Answer truthfully about their dx -Structured and consistent environment is important -Forgetful about family members/themselves (PROSOPAGNOSIA) ----Use REMINISCENCE therapy and talk about something in room that is personal (HAVE PERSONAL ITEM IN ROOM) ----Have a picture of the patient on the door so they can recognize themselves and location if pt eloped ----Not unusual for them to talk to themselves in the mirror - No abstract paintings, pictures on the walls of people or animals that can be mistaken as being able to harm pt, room should have nonglare lighting, no frightening shadows -Avoid distractions / objects kept in same place/ establish a routine - If in new environment, select a quiet, private if possible room that is away from obvious exits -Redirection - speak in short, clear sentences - VALIDATION THERAPY VS REALITY ORIENTATION -Structured activity / frequent walks / seizure activity calm voice to redirect - PT and OT work w/ pt and give adaptive devices PRN - Toileting schedule Q2h to prevent incontinence - Imporve communication -Prevent Injuries -Managing Care Giver Role Stress
Risk Factors for Dry AMD
- Smoking - Htn - Female - Short stature - Family hx - Long-term DIET POOR IN CAROTENE AND VIT E
Some Ototoxic drugs
- Some antibiotics - NSAID's - Chemo agents - Some diuretics
S/S of Angle-closure glaucoma
- Sudden, severe pain around the eyes that radiates over the face - Headache or brow pain - Nausea/ Vomiting - Colored halos around lights - Sudden blurred vision with decreased light perception - Sclera may be red - Shallow anterior chamber, cloudy aqueous humor, and moderately dilated and nonreactive pupil
Enophthalmos
- Sunken appearance of the eye
Mgmt for Caregiver Role Strain Chart 42-16 pg. 880
- Support Groups - Recognize own stress and seek help for own problems - Accept help for caring for loved one - Alzheimer's Association - Respite Care- Can have loved one cared for over the weekend or for weeks to give care giver a break
Who is the best person to obtain a hx from in a pt w/ Alzheimer's?
- The care giver
Spondylolisthesis
- The vertebrae slips forward onto the one below it as a result of Spondylosis - Pressure on nerve roots, pain, numbness
Causes of HD
- Transmitted by autosomal DOMINANT trait [means that a person needs only ONE copy of the defective gene to develop the disorder]
Light Reflex
- Triangle of light expected on the ear drum - RIGHT EARDRUM: appears on the RLQ of ear - LEFT EARDRUM: appears on the LLQ of ear - DIFFUSE: When it appears spotty or in multiple locations due to misshaped eardrum
Neoplasms
- Tumors in the middle ear are rare. -Problem is that it can disrupt conductive hearing , erode the ossicles, and spread to the inner ear and cranial nerves. - S&S- Progressive hearing loss and tinnitus. Bulging eardrum or visible mass -Diagnosis: CT or MRI, and Angiography and Tomography -Treatment: Surgery- remove mass
Key Assessment Components Pg 838, Chart 41-2
- Two types of Neuro Assessments: 1) Complete and 2) Rapid -Family history, genetic risk -Current health problems -Level of consciousness/orientation -Memory and attention -Language, higher levels of cognition -Cranial nerve assessment -Sensory function -Motor function -Cerebellar function
Earwick
- Used for instillation of antibiotics into the external canal. When edema occludes the external auditory canal, it is difficult for antibiotic solutions to enter the canal adequately. -An earwick is placed through the meatus. -Solutions placed on the external portion of the earwick are absorbed through the canal.
Furuncle (boil)
- Usual staph infection of hair follicle S/S: -Pain, swelling and redness. - Eventual purulent head-- no drainage until it ruptures - Tx- heat and local antibiotics. I&D if needed.
Opthalmoscopy
- Views external and interior structures - In dark room is best since pupils dilate in dark - AVOID using in a confused pt
DX TESTS
- Visual acuity tests - EOM fn - Color vision - CT - MRI (METAL IN EYE ABSOLUTE CONTRAINDICATION) - Radioisotope scanning - Ultrasonography - Slit lamp - Tonometry - Opthalmoscopy - Fluroescein Angiography ( Image of circulation: good for Diabetic Retinopathy and Macular Degeneration) - Electroretinography (Retina's response to stimulation) - Gonioscopy (DETERMINES if it is open or closed glaucoma) - Laser imaging of the retina and optic nerve (3D view of the back of the eye i.e. Optomap)
Consensual Response
- When light is shined into right pupil, left constricts also (normal)
CNS and PNS
- Work together to receive an impulse, interpret it, and initiate a response, enabling the individual to maintain a high level of adaptation and homeostasis -Controls both cognitive function and voluntary and involuntary activities
PNS
-Detects changes in internal and external environment -Divided into: ---Spinal Nerves ---Cranial Nerves ---Autonomic Nervous System (ANS) (sympathetic and parasympathetic) -Transmits information to the CNS -Responds appropriately -Maintenance of homeostasis -Two divisions ---Afferent (sensory) ---Efferent (motor)
MACULAR DEGENERATION (MD)
-Deterioration of the macula (which is the area of central vision) - Can be age related or exudative - LOSS OF CENTRAL VISION!!! - NO CURE
Healing on its own
- takes a long time
Keratoconjunctivitis Sicca
-"Dry eye syndrome" -Changes in tear composition, lacrimal gland malfunction, or altered tear distribution -Artificial tears, lubricating ointment*** -Surgery - Photophobia - Light reflex is dulled - Foreign body sensation - Lubricating ointment
PNS: Spinal Nerves and Autonomuc NS (parasympathtic and sympathetic)
-31 pairs of spinal nerves ---8 pairs of cervical nerves ---12 pairs of thoracic nerves ---5 pairs of lumbar nerves ---5 pairs of sacral nerves ---1 pair of coccygeal nerves -Spinal nerves are all classified as mixed nerves because they contain motor and sensory pathways that produce motor and sensory activities
Common Causes of Cataracts Pg 982, Table 47-2
-AGE related - Congenital -Traumatic - penetrating eye injury -Toxic cataracts - corticosteroids -DM -Glaucoma surgery
Uveitis
-ANTERIOR Uveitis= Inflammation of iris or ciliary body ---May be caused by systemic diseases -POSTERIOR Uveitis (Retinitis) -CHORIORETINITIS ---Inflammed choroid and retina ---TB, syphillis, toxoplasmosis -Onset slow and painless -Reduced vision d/t fluid, fibrin, and leaking into vitreous cavity
Risk Factors for developing Alzheimers
-Age -Head trauma -Inflammatory factors -Female gender -Family History
Bell's Palsy aka Facial Paralysis
-Bell's palsy is a ACUTE paralysis or weakness of the muscles on ONE side of your face from CN VII - May be cause by virus -Higher incidence in DM -Damage to the facial nerve causes that side of your face to droop -Acute onset & gets better on its own within a few weeks CAUSES: -Idiopathic -Infections that trigger the HSV 1
Refraction
-Bends light from the outside into the eye through curved surfaces and refractive media to the retina -EMMETROPIA: "perfect vision"- perfect refraction of the eye
Vitreous Hemorrhage
-Bleeding into vitreous cavity (age, trauma) -Apply ice immediately -Vitrectomy
Divisions and function of nervous system
-Central -Peripheral -Autonomic (sympathetic and parasympathetic)
Brain (Fn's are printed on a separate WS from the PPT)
-Cerebrum -Cerebellum ---Coordination and maintains negative feedback mechanism ---Unsteady gait if problems here -Brain stem (RESPIRATORY control center where the medulla oblongata is located- RN PRIORITY is breathing) -Subcortical structures ---Basal nuclei ---Thalamus ---Hypothalamus
EXAM: Tensilon Testing
-Cholinesterase Inhibitors edrophonium chloride (Tensilon) is given and along with Neostigmine bromide (Prostigmin) - Tensilon allows ACH to bind to the receptors, with MG pts, there will be an improvement in muscle tone that lasts 4-5mins -Onset of muscle tone improvement within 30 to 60 sec after injection of Tensilon (for most patients); lasts 4 to 5 minutes -If muscle tone improves = a positive diagnosis for MG - Can also use this test for dx of Cholinergic and Myasthenic crisis -CAUTION w/ this test because it can cause CV problems (V fib or brady) -----Atropine at bedside to counteract this adverse effect and call a code if this occurs
Cataract
-Clouding and blurring of lens -Surgery is only cure (Specs are used 1st) -Opacity makes it difficult to see retina S/S: - Pupils change from black to GRAY/BLUISH/WHITE -Visual acuity restricted - Blurred Vision - Decreased color perception - Double Vision -NO pain or eye redness - Absent red reflex
HEARING LOSS Pg 1009, Table 48-2
-Conductive (difficulty in the external ear or the middle ear) -Sensorineural (difficulty in the inner ear or the acoustic nerve) -Mixed conductive-sensorineural (a combination of the two) - Presbycusis
Eye Donation
-Corneal tissue from donors -Donors must be free of infectious disease or cancer at time of death *If deceased pt is a known donor:* - Raise HOB to 30 degrees - Instill antibiotic drops - Close the eyes and place a small ice pack
Motor Response
-Does the patient follow commands easily? -Does the patient respond to touch or stimuli? -Can the patient move independently? -Decorticate and Decerebrate what is the difference? -Does the patient pull away from your touch?
EXAM: Stages and S/S of Alzheimers Pg 873, Chart 42-13
-FIRST SIGN: memory loss -Can be subtle, initially overlooked - SUNDOWNING! Pt gets worse at night time - Traumatic relocation Syndrome: when the pt reacts excessively aggressive to any change that occurs i.e. being admitted to the hospital -Stage I or Early (Mild): first symptom up to 4 years -Stage II or Middle (Moderate): (2 to 3 years) -Stage III or Late (Severe): ---Severe Cognitive Decline ---Loss of ability to respond to environment ---Inability to communicate ---Total care required ---Loss of ability to control movement ---Abnormal reflexes, muscle rigidity ---Swallowing impaired
Education Pg 922, Chart 44-5
-Factors in exacerbation - Avoid Infection, stress, surgery, hard physical exercise, sedatives, enemas, strong cathartics - Avoid respiratory complications -Avoid overheating, crowds, overeating, erratic, changes in sleep habit, emotional extremes -Teach warning signs - Nutrition- take meds at regular time and take meds 45 mins before meals -Importance of compliance - Family to learn CPR - Enteral may be needed - PT maintained and encourage Passive or Active ROM - Emotional support - Rest periods during the day to prevent crisis - Avoid extreme hot and cold - Identify S/S of the Crises - Medical bracelet needed
Fn of the Lobes of the Brain Pg 831, Table 41-1
-Frontal Lobe: Broca's Area= Speech area, High level cognitive fn, memory storage, controls voluntary eye movement -Temporal Lobe: Wernike's area= Language, auditory receptors, -Parietal Lobe: Primary sensory quarters, responsible for visual and spacial info, determine size, shape, and wt of things. -Occipital: Vision, reflexes and onterpretation of sight
Electroencephalography (EEG)
-Graphically records electrical activity of cerebral hemispheres - Looks for activity in the brain - Clean pt after since electrodes make them sticky -Patient must be sleep-deprived before procedure -Anticonvulsants may be withheld Pg. 848-849
Complications of Anterior Cervical Diskectomy Pg 892, Chart 43-7
-Hoarseness due to laryngeal injury -Temporary Dysphagia -Wound Infection -Injury to spinal cord/nerves -Dura mater tears with leaks -Loosening of screws and grafts
EXAM: Trigeminal Neuralgia (tic Duloureux)
-Idiopathic - CN V affected ----Trigeminal nerve controls Opthalmic, axillary, and mandibular fns S/S: -Sudden, severe, electric shock-like, or stabbing pain that lasts several seconds (WORSE PAIN IN MED HX) - Can be 100x a day or just a few time a year -Can occur when a person is brushing the teeth, putting on makeup, anything touching the face -More common in women than in men DX -MRI NONSURGICAL MGMT -PAIN MGMT (Priority care) -Antiseizure drugs Tegretol (carbamazepine) or Neurontin (gabapentin) -The medications Klonopin (clonazepam) and Depakote (divalproex sodium) to achieve pain relief. -Antidepressant drugs have pain relieving effects. -Alternative therapies such as acupuncture, chiropractic adjustment, self-hypnosis, or meditation SURGICAL MGMT -Microvascular decompression ---Moving the nerve out of the area where it is- RISK: nerve damage -Percutaneous Stereotactic Rhizotomy ---Severing nerve root using Radiofrequency thermal coagulation and Percutaneous balloon microcompression ---Some fn loss but not all POST OP CARE -In addition to general care also include post craniotomy care - Monitor patient for complications: headache, cranial nerve dysfunction, bleeding - Apply ice to cheek and jaw for 3-4 hrs - Avoid chewing on affected side until paresthesias resolves - Soft diet - Avoid rubbing eye due to loss of pain sensation - Inspect eye daily - Report blurred vision - Frequent dental exams due to loss of pain sensation
Meds for Tx
-Include anticholinesterase and antimyasthenics ---i.e. Pyridostigmine (Mestinon, Regonol)--enhance neuromuscular impulse transmission by preventing decrease of ACh by enzyme ChE ---Improves muscle strength ---1st line drug (eat 45mins after to avoid aspiration and watch for adverse effect of Cholinergic crisis) (These drugs are withheld if pt is ventilated) ---Administer with food to reduce GI symptoms ---Observe drug interactions ---Give on time to maintain levels and improve muscle strength -Immunosuppressants - IV immunoglobulin {IVIG} - attack IG - not myelin sheath -Immunosuppresants ---Corticosteroids/chemo drugs
GLAUCOMA
-Increased ocular pressure leading to visual impairment/blindness -Cupping and atrophy of optic disc TYPES: -Primary open-angle glaucoma (women & Asian) ---Fluid follows normal path through the iris, but it is draining slowly ---Increases pressure on the lens and retina -Angle-closure glaucoma (aka acute glaucoma) ---Female Asians most at risk ---Fluid is not draining at all ---EMERGENCY ---Pressure quickly increases and can cause hypoperfusion of the retina and lose of vision
Meningitis Pg 864 Table 42-2
-Inflammation of the meninges that surround the brain and spinal cord - Causes Increase ICP - Can be caused by bacteria, virus, chemo drugs, NSAID's, immunocompromised, direct routes i.e. trauma, surgery TYPES (Bacterial is the big problem here!) -VIRAL aka Aseptic Meningitis ---Self limiting & complete recovery ---Most common ---Caused by HSV-2 and Varicella Zoster Virus, Mumps, HIV - CRYPTOCOCCUS NEOFORMANS ---Most common fungal meningitis -BACTERIAL (Worse!) ---Life threatening if untreated within a few days --- Strep pna and Neseirra meningitidis (Meningococcal) common causes ---Meningococcal is MEDICAL EMERGENCY ---Highly contagious ---Occurs in areas of high population i.e. dorms, military barracks, and crowded living areas
S/S of Encephalitis
-Inflammatory response that does not involve pus formation - Fever -N&V -Stiff neck / nuchal rigidity - Focal neurological deficits - Joint pain -S/S of increased ICP -Changes in mental status - agitation -Motor dysfunction - dysphagia -Vertigo -Photophobia/phonophobia -Fatigue/ joint pain/ headache -Headache / LOC -Sudden change in mental functions: ---"Flat" mood, lack of mood, or mood that is inappropriate for the situation ---Impaired judgment ---Inflexibility, extreme self-centeredness, inability to make a decision, or withdrawal from social interaction ---Less interest in daily activities ---Memory loss (amnesia), impaired short-term or long-term memory EMERGENCY S/S: -Loss of consciousness, poor responsiveness, stupor, coma -Muscle weakness or paralysis -Seizures -Severe headache
Stages of GBS
-Initial period [1-4 weeks]: onset of 1st symptoms end when there is no further deterioration -Plateau period - several days to 2 weeks -Recovery phase - gradual 4 - 6 months maybe 2 yrs- remyelinization to return to baseline or best recovery
Verbal Responses
-Is the patient oriented to person, place & time? -Is the patient speaking legibly? -Is the patient responding to you? -How is the patient acting- appropriate or inappropriate? -Is the patient intubated?
Dx of GBS
-Lumbar puncture ---A spinal needle is inserted between the lumbar vertebrae L3/L4, L4/L5 or L5/S1 --- High amt of Protein in CSF = DX (up to 2 weeks of disease process for results to show) ---Complications -------Spinal headache/bleeding/infection -MRI/CT rule out other causes of motor weakness -Resp compromise = ABG -Electrophysiologic Studies (may take 4 weeks of disease process to show up)
Diagnostic Studies of the Nervous System Pg 846-847, Table 41-4
-Lumbar puncture & Cerebrospinal fluid analysis -Blood cultures (necessary) -Radiologic studies ---X-Ray- Skull and spine ---CT Scan: To dx tumors and infection (possibly with contrast medium; assess for allergic response, fluids) ---Cerebral angiography ---MRI/MRA (Good to see vessels in brain--NO METAL) -Electrographic studies ----Electroencephalography (EEG) ----Electromyography and nerve conduction studies (EMG) ---Evoked potentials - nerve conduction studies -Positron emission tomography (PET) -Single-photon emission CT -Magnetoencephalography (MEG) -Ultrasound ---Carotid duplex studies ---Transcranial Doppler Ultrasonography -Muscle and nerve biopsy
Evoked Potentials
-Measure electrical signals to brain generated by hearing, touch, sight ---Auditory ---Visual ---Somatosensory
Interventions for Bells Palsy
-Medical management --Prednisone (decrease inflammation), analgesics, acyclovir (viral cause) --Tegretol for pain --Protection of eye -----Manually close eye at intervals and instill drops -----Assist in dry tears -----Patch or tape eye at night --Nutrition (Risk for aspiration) -----Eat and drink on unaffected side -----High calorie snacks and soft diet --Massage, warm/moist heat --Facial exercises- Grimace, whistle, wrinkle brow, force eyes closed, blow ait out of cheeks 3-4x daily for 5 mins --PT SURGICAL: - Decompress facial nerve - Cosmetic surgery *Recovery usually within few weeks or mos, but some have perm damage*
Warning signs for development of Alzheimers
-Memory loss -Difficulty performing familiar tasks -Problems with language -Disorientation -Decreased judgment -Problems with abstract thinking -Misplacing things -Changes in behavior (Sundown) -Changes in personality -Loss of initiative (Decrease in ADLs)
Drugs for Alzheimers
-Monozmine oxidase (MAO) inhibitors -Dopaminergics -Dopamine agonist -Anticholinergics -Antidepressants- especially amitriptyline are used to treat depression -Propranolol- may be used to treat tremors -Cholinesterase inhibitors - delay destruction of acetylcholine - promote neurotransmission (Aricept, Reminyl) -Namenda NMDA- receptor agonist blocks excess glutamate that destroys nerve cells -No cure - manage symptoms only [confusion & agitation] -EVENTUALLY ALL THESE DRUGS LOSE EFFECTIVENESS; A FLUCTUATING RESPONSE TO DRUGS IS CALLED THE ON—OFF RESPONSE
Risk Factors for Meningitis
-Otitis media, pneumonia, acute/chronic sinusitis, brain, tooth abscess -Tongue piercings -Infection of the head and neck -Spinal surgery -Bacteria enter the CNC via the blood stream at the blood brain barrier -Results in increased intracranial pressure as a result of blockage of the flow of CSF, change in cerebral blood flow, or thrombus formation.
Pupillary Assessment
-PERRLA -Brisk or sliggish? - Nonreactive/ fixed?
Assessment of the eyes
-Patient history -Nutrition history (VIT DEFICIENCY I.E. VIT A) -Family history and genetic risk (I.E. CATARACTS) -Current health problems (I.E. DM, HTN, MEDS) -Near vision -Visual field -Extraocular muscle function -Color vision
Dx of MS
-Physical Examination -Patient's report of symptoms -MRI -Lumbar Puncture (PRESENCE OF IgG BANDS) -US (brain/ventricles) controversial -Electroencephalography
How do you instill Eardrops? Pg 1004, Chart 48-3
-Position the affected ear uppermost -Pull outer ear upward and backward (>preschoolers) -Pull outer ear downward and backward for infants and toddlers under 3 years -Place drops so they run down the wall of the canal -Have patient to lie on unaffected ear to encourage absorption
S/S of GBS Pg 914, Chart 44-1
-Progressive motor weakness -Sensory abnormalities -Initial muscle weakness & pain - Paresthesia - Pain - Muscle Weakness - Severe nigh time pain - RESPIRATORY COMPROMISE!! - Bowel and bladder dysfn -ASCENDING paralysis (begin in legs ans spread to arms and upper body) ----G- Ground to B- Brain ----When it reaches the chest the concern is RESPIRATORY -Autonomic dysfunction ----Changes in heart rate & rhythm, B/P changes i.e. HTN & orthostatic -Dysphagia -No cough/gag
RN Care for ALS
-RESPIRATORY CARE IS CRUCIAL (resp mgmt and prevent infection) -PREVENT ULCERS -PREVENT VTE AND FALLS - No specific therapy, interventions to maintain / improve quality of life -Most patients managed @ home -Hospitalized for nutrition problems, pneumonia & respiratory failure -May have PEG tubes for feeding -Noninvasive ventilators for respiratory support Muscle atrophy ---Resp support {BiPAP}, IPPV, and Mechanical ventilation ----Diaphragmatic Pacing: pacemaker-like application that is placed and sends impulses to diaphragm resulting in inhalation -Physical therapy & Occupational therapy -Life support decisions made by patient & family, "living will" -PALLIATIVE care - comfort and support -Consider the patient's ADVANCE DIRECTIVES to assist in planning care for respiratory failure in terminal stages of the disease. -Provide supportive care
General Post op Instructions
-Reinforce dressing only - Check drainage color to make sure it is not CSF -Avoid nose blowing, sneezing & coughing -Observe for complications: -Facial nerve damage - maybe transient -Infection -Vertigo, tinnitus -Do not apply any pressure if bleeding - call MD -Administer medications -Provide for patient safety -Discharge education: avoid swimming, flying & crowds
Plasmapheresis Pg 915, Chart 44-2
-Removes circulating antibodies assumed to cause disease -Plasma selectively separated from whole blood; blood cells returned to patient WITHOUT plasma -Plasma usually replaces itself, but patient is transfused with ALBUMIN to prevent HYPOVOLEMIA from removal of plasma - Done w/in days of onset of illness but can be up to 30 days after onset - 3-4 tx 1-2 days apart - Fistula used RN CARE: - Provide info and ressurance - Monitor bleeding ans electrolytes - Wt pt before and after - Care for shunt or venous access ---Bruit and thrill Q2-4h ---Bulldog clamps nearby ---Assess for bleeding - Prevent complications
Priority Care
-Respiratory (gag relfex, VS, Respiratory assessment) -Nutrition (small, soft meals, check electrolyte, mouth care, voiding, bowel movement -Skin Care (turn, VTE, heparin, eyecare artificial drops)
Assessment of ALS
-Respiratory concerns -Swallowing concerns -Musculoskeletal concerns
RETINAL DISORDERS
-Retinal Detachment - Retinal Hole - Retinal Tear
Retinitis Pigmentosa
-Retinal nerve cells degenerate and the pigmented cells of the retina grow and move into sensory areas and leads to blindness -Inherited Disorder ---Autosomal dominant trait ---Autosomal recessive trait ---X linked recessive trait ---Common in CHILDHOOD S/S: - Night blindness - Decreased acuity - Total Blindness - Lacy Pattern - Cataracts may accompany Dx: -Electroretinography TX: -No current therapy -Avoid Accutane (isotretinoin), sildenafil (Viagra) -Wear sunglasses -Supplements: DHA, Omega 3, antioxidants, beta carotene, Vit A, lutein, zeaxanthin
Meds for ALS
-Rilutek (riluzole) may be neuroprotective in early stages ---Extends survival time - Baclofen (lioresal) for spasticity
Dx of ALS
-Rule out other disease and Based on S/S -No specific tests ---Creatinine Kinase usually increased ----EMG usually shows fibrillation and fasiculations of the muscles -No known cause [viral, genetic & environmental]
EXAM: S/S of MS Pg 905, Chart 43-14
-Sensory loss (ie, paresthesias) - Usually an EARLY complaint -Spinal cord symptoms (motor) ----Muscle cramping secondary to spasticity -Spinal cord symptoms (autonomic) ---Bladder, bowel, and sexual dysfunction -Cerebellar symptoms ---Charcot triad of dysarthria, ataxia, and tremor ---Intention tremor ---Dysmetria - inability to direct movement -Optic neuritis -Trigeminal neuralgia ---Bilateral facial weakness or trigeminal neuralgia -Facial myokymia (irregular twitching of the facial muscles) - May also be a presenting symptom -Eye symptoms ---Diplopia on lateral gaze ----Blurred vision ----Nystagmus ----Scotomas (changes in peripheral vision) -Heat intolerance -Constitutional symptoms ----Fatigue (which occurs in 70% of cases) and dizziness; ----Fatigue must be differentiated from depression (which may, however, coexist), lack of sleep, and exertional exhaustion due to disability -Pain -Subjective cognitive difficulties ----Attention span, concentration, memory, and judgment -Depression - A common symptom -Euphoria - Less common than depression -Bipolar disorder or frank dementia ----May appear late in the disease course but is sometimes found at the time of initial diagnosis. -Symptoms associated with partial acute transverse myelitis
Conjunctival Hemorrhage
-Small, well-defined area of bright red hemorrhage under conjunctiva -No pain -No visual impairment -Resolves in 14 days without treatment (unless other S/S) - Monitor VS
Stages of HD
-Stage 1- onset of neurological or psychological symptoms [5yrs] -Stage 2- increased dependence on others for care [5yrs] -Stage 3- loss of independent function
Meds
-Tetrabenazine (Xenazine) is specifically approved to suppress the involuntary jerking and writhing movements (chorea) ----A serious side effect is the risk of worsening or triggering depression or other psychiatric conditions. -Antipsychotic drugs, such as haloperidol (Haldol) and chlorpromazine, have a side effect of suppressing movements...beneficial in treating chorea. These drugs may worsen involuntary contractions (dystonia) and muscle rigidity. -Newer drugs, such as risperidone (Risperdal) and quetiapine (Seroquel), may have fewer side effects but still should be used with caution, as they may also worsen symptoms. -Other medications that may help suppress chorea include amantadine, levetiracetam (Keppra) and clonazepam (Klonopin). ----At high doses, amantadine can worsen the cognitive effects, but it may also cause leg swelling and skin discoloration
S/S of Bells Palsy
-The nerve damage may also affect your taste, make tears and saliva - Loss of corneal reflex - Loss of taste - Increased tearing -Sudden weakness or paralysis / difficulty closing eye -Facial droop -Drooling -Excessive tearing or a dry eye -Loss of ability to taste -Pain in or behind your ear -Numbness -Increased sensitivity to sound
Peripheral Nervous System
-The peripheral nervous system is composed of the spinal nerves, cranial nerves, and autonomic nervous system -Its function is to provide communication from the brain and spinal cord to other parts of the body
Dx Tests for MG
-Thyroid function (thyrotoxicosis- elevated TH) -Acetylcholine receptor antibodies -Thymoma - repetitive Nerve Stimulation (shows decline in CMAP) - Electromyography (Decrease in amplitude of the electrical wave form) ---Determines how well the motor neurons are stimulated -Tensilon Test
Amyotrophic Lateral Sclerosis (ALS, Lou Gehrig's Disease)
-Unknown cause -ADULT onset - UPPER & LOWER motor neuron disease - Muscles and Neurons become stiffed and sclerosed -Affects men > women, 5th or 6th decade of life - Brain is not affected (intact), but the impulses are not working -Loss of motor neurons in anterior horns of spinal cord & lower brainstem -Starts in 1 area of body, motor weakness, and deterioration and spreads until entire body is involved -Affects ability to talk, swallow & breathe -Death occurs within 3 years - NO TX, STANDARD PATTERN OF PROGRESSION, OR METHOD OF PREVENTION
Causes
-Vehicular or sports injury -Wounds to peripheral nerves -Partial / complete severance -Ischemia -Depends on degree & type of injury
Surgery for Otitis Media Pg 1007, Chart 48-6
-Ventilatory tubes - inserted in eustachian tubes for drainage (small grommet inserted) -Myringotomy - incision to relieve pressure -Tympanoplasty - surgical reconstruction of the ossicles & membrane if damaged or rupture occurs. POST OP CARE - No water allowed in ear. - Keep head dry post procedure X 1 week and ear dry 6 weeks. -No use of straw for 2/3 weeks. -No straining. - Bedrest & turn head with affected side up for the first 12 hours. - Apply heat or cold pack for comfort
Lumbar Puncture
-With the patient in FLEXED position to maximize the space between vertebrae, the lumbar puncture needle is inserted between L4 and L5 to gain entry to the subarachnoid space. (During actual procedure patient would be gowned and draped to protect privacy.) RN PRIORITIES - Pt cannot move during procedure -Position for procedure is fetal- side lying with legs flexed - Need informed consent - Monitor for bleeding and drainage - Bed-rest 6-8h after - No sitting up fast due to headache
Four eye fns to provide clear images and vision
1) Refraction 2) Pupillary Constriction and Dilation 3) Accommodation 4) Convergence
EXAM: Types of MS
1) Relapsing-remitting- S&S develop and resolve within a few weeks/ mos- Most common 2) Primary progressive - steady neurological deterioration w/ no remission of S/S 3) Secondary progressive - begins with a relapsing remitting and deteriorates 4) Progressive-relapsing - frequent relapses with partial recovery, but NOT A RETURN TO BASELINE
Three layers of the eye
1) Sclera (external) 2) Uvea (middle): choroid, ciliary body, and iris 3) Retina (innermost)
Normal pupil diameter
3-5mm
How many spinal bone are there total?
31 31 PAIRS of spinal nerves
Posturing
A, Decorticate posturing (Towards body) B, Decerebrate posturing (Away from body)
Post Keratoplasty Teachings
ABC's #1, then check eyes - Eye is covered w/ pressure patch and protective shield - Pt to lie on nonoperative side to reduce IOP - Teach how to apply patch - Pt to use shield at night, around animals or children for first month post op - DO NOT use ice pack - Teach how to apply gtts - Examine eye daily - Protect eye from activities that increase IOP (jogging, running dancing, more) - Report any complications i.e. floaters, excessive drainage, S/S of bleeding, flash of light, photophobia, eye pain, graft rejection (cloudy cornea, reduced vision)
Specific Tests for the Ear
AUDIOMETRY - Measures degree of loss - Measures acuity of auditory sensory perception - Tests Frequency, Intensity, and Threshold PURE-TONE AUDIOMETRY - Tests for frequencies of normal hearing, speech, music, and other common sounds - Via headphones- typical test done at schools - Can be done via air conduction testing (headphones) or bone conduction (vibrations on the mastoid) SPEECH AUDIOMETRY - Speech Reception threshold- min loudness person can repeat a word SPONDEE used (2 syllable words) -Speech discrimination- Ability to discriminate between similar sounds among words- monosyllabic TYMPANOMETRY - Assess mobility of the eardrum and structures in the middle ear AUDITORY BRAINSTEM- EVOKED RESPONSE - Electrodes used - Used when pt is unsuccessful in other tests
QUESTION: A patient is reporting ear pressure, dizziness, and decreased hearing. What should the nurse do? A) Examine the ear for excessive ear wax (cerumen). B) Ask the patient if he or she is experiencing headaches, malaise, or pain. C) Establish a timeline for the patient's symptoms. D) Examine the patient's hearing acuity.
Answer: B Rationale: Acute and/or chronic otitis media will have multi-symptom presentation that includes conductive hearing loss, pain, headaches, malaise, fever, dizziness, nausea, and vomiting. Excessive ear wax can obscure hearing acuity and is a common condition in older adults. Patients may develop chronic otitis media, and frequency/pattern of symptoms is important for treatment.
Which is a priority intervention after a patient receives a corneal transplant? A) Keeping the eye covered for the first 24 hours postoperatively B) Avoiding straining to have a bowel movement C) Keeping the eye moist D) Assessing the eye for signs of infection
Answer: B Rationale: The patient should avoid activities that increase intraocular pressure (IOP) because they can interfere with corneal graft take. Activities such as straining to have a bowel movement, sneezing, coughing, vomiting, and bending over should be avoided. Other postoperative considerations include keeping the eye moist and covered with a protective eye patch, and daily assessment for signs of bleeding, infection, or graft rejection.
QUESTION: A priority nursing intervention for a patient with tinnitus is: A) Evaluate medications for ototoxicity. B) Encourage music or soft white noise during sleeping hours. C) Acknowledge the psychological stressors of the disorder. D) Provide education on loudness levels to prevent hearing loss.
Answer: B Rationale: Tinnitus is a challenging hearing condition that lacks exact diagnostic testing. Tinnitus can disturb sleep patterns. Offering soft music or white noise can help the patient sleep. Other interventions include reviewing medications that may exacerbate the condition or alter hearing, exploring the patient's coping and stress related to the condition, and discussing noise levels that may muffle the ringing sensation without damaging hearing.
QUESTION: Which is a nursing intervention for maximizing communication with a patient with hearing loss while he or she is under Airborne Precautions? A) Speak loudly. B) Turn the TV volume down or off. C) Speak clearly and slowly. D) Ensure that you have the patient's attention before speaking.
Answer: C Rationale: Airborne Precautions requires wearing a mask while in close contact with the patient, thereby removing the patient's ability to read lips. When communicating with patients that have difficulty hearing, speaking clearly, slowly, and closer to the patient is most helpful. Other strategies to assist with communication include reducing noise in the room, ensuring the patient is engaged with you, and projecting the voice but in a lower tone.
Which patient is at greatest risk of developing primary angle-closure glaucoma? A) 32-year-old Caucasian female B) 42-year-old Hispanic/Latino male C) 52-year-old Asian female D) 64-year-old African-American male
Answer: C Rationale: The risk of glaucoma begins after age 40 for all races. Primary angle-closure glaucoma (also called PACG or acute glaucoma) is more common in women and Asians. African-Americans and Hispanics have a greater tendency for developing primary open-angle glaucoma than do people of other ethnicities.
QUESTION: What are postoperative expected outcomes for a patient who has undergone surgery for cataract removal? A) Pain early after surgery accompanied by nausea and vomiting B) Change in visual acuity accompanied by tearing and redness C) Yellowish drainage and photophobia D) Mild itching and bloodshot appearance
Answer: D Rationale: Mild itching and bloodshot appearance are considered to be normal postoperative outcomes for this patient. Pain early after surgery may indicate increased intraocular pressure or hemorrhage. Change in visual acuity accompanied by tearing and redness and any yellowish drainage and photophobia can be signs of infection.
Optic fundus
Area of the back of the eye that can be seen with an opthalmoscope
EXAM: Why does a pt have to be in a prone position post retinal oil/gas injection?
Because gravity pushes air into the retina and puts it in place
Categories of Hearing Loss
CONDUCTIVE HEARING LOSS - From obstruction of sound wave i.e. foreign body, tympanic membrane problems, or fused bony ossicles SENSORINEURAL HEARING LOSS - From defect in cochlea, CN VIII, or the brain i.e. exposure to loud music can cause this MIXED CONDUCTIVE-SENSORINEURAL HEARING LOSS - mix of the two
Otitis Media
CAN LEAD TO - Mastoiditis - Perforation of tympanic membrane - Residual deafness TYPES: -Acute -Chronic -Serous CAUSED BY: - Biofilm (group of bacteria that take over a part of the body) - Throat infection - URI - Gonorrhea - Bacteria / viruses -Chronic -common in children S/S: - Pain - Fever - Malaise - Inflammation - Bulging Tympanic membrane - Possible tympanic rupture (relief of pain with drainage) -Headache - Tinnitus- ringing in the ears -Deafness -Head rolling, crying, ear-hugging - child - Nausea - Vomiting TX: - Gtts (do not use cotton to keep med in ONLY gauze) or PO meds ---Antibiotic ---Analgesics- NSAID, Tylenol. ---Antihistamines - decrease fluid in middle ear ---Nasal decongestants - Surgery
S/S of Parkinson's Pg 868, Chart 42-11
CARDINAL S/S: - Resting Tremor - Muscle Rigidity - Bradykinesia or Akinesia - Postural Instability OTHER S/S: -Orthostatic - Mask-like face - Changes in speech -Bowel and bladder problems - Emotional changes - depression, irritability, pessimism, fear and insecurity -Monotonous speech - Heat intolerance
Cervical Neck Pain
CAUSES: - Most common cause is a herniated disc resulting in spinal nerve root compression and motor and sensory S/S ---C5 and C6 most affected - Ostephyte (bony spur) may also cause this - Muscle Strain - Ligament sprain form aging - Poor posture - Lifting - Tumor - RA - Osteoarthritis - Infection DX: - X ray - CT - MRI - Bone scan - Myelogram/ post- melogram CT - Electromyography/ nerve conduction studies NONSURGICAL MGMT - Same as for lower back pain - Also use soft collar (NO LONGER THAN 10 DAYS) along w/ chiropractic care SURGICAL: - Conventional Open most common - Anterior or Posterior cervical diskectomy can be done ---Pt fitted with large neck brace pre op ---PRIORITY RN care is ABC's!! - MIS also available and the same care as for lower back pain
Promoting Independent Living in a Older pt w/ Impaired Vision Pg 987, Chart 47-5
COMMUNICATION -Auditory traffic signals to say when it is safe to cross - High contrast colored curbs - Libraries have large print books and books on disc - Talking clocks, watches, and timers - Playing cards, games, menus, calendars, and instructions come in large print - Computer keyboards high contrast and large print - Adaptive items - Mention food location like the face of a clock - Use NORMAL tone when speaking. SAFETY - Orient to the room by using a central point i.e. the chair in to the left of the bed and the table is to the right of the bed - Do not move their furniture or other things around unless they are aware and in agreement - With black marker and tape mark the 350 degree on oven and 70 degree on ac - Paint light switches with a deep color to make it stand out - Label canned good with large black letters - Teach pt to feel for the openings of drinks i.e. milk cartons - Differentiate drugs by altering the shape of the bottle i.e. put rubber band on one - Immediately orient the pt to the room and never leave pt alone in a room that they are not oriented to - Walk pt to the bathroom and orient them to the bathroom - Be specific with descriptions and avoid using hand gestures - Mealtime use the face of a clock to locate food AMBULATION - Ambulate with the pt holding your arm at the elbow and keep your arm close to your body - Warn the pt if there are obstacles in the way - Pt may use a cane SELF-CARE - Pt needs to feel they can control their environment - Knock on the door when entering - Introduce self and tell them why you're there - Put a sign on the door SUPPORT - feel they have lost a body part and will be grieving - Help them towards acceptance
Trauma
Causes: - Barotrauma (excessive nose blowing that increases pressure), blunt force, infection, foreign objects, etc. - Can cause perforation of the ear drum ---Perforation heals within 1-2 wks w/out tx, but if repeated perforations, heals slowly with scarring -TX: Hearing aids, tympanoplasty, or myringoplasty. -Nursing care: teach about trauma prevention, ear hygiene, ear protectors
Restless Legs Syndrome (RLS)
Characterized by Leg paresthesias and Irresistible urge to move ----Peripheral and central nerve damage in legs/spinal cord -Hereditary, pregnancy, -Peripheral neuropathy MGMT -Nonmedical treatment ----Avoid caffeine, alcohol, quit smoking, lose weight ----Walking, stretching, warm bath -Drug therapy effective for some patients ----Dopamine agonists - Mirapex & Requip , Gabapentin, Sinemet
What do pts w/ HD usually die from?
Complications -Pneumonia or other infections -Injuries related to falls -Complications related to the inability to swallowing
Six Degrees of Injury
Pg 923-924
Conductive
Disorders in the auditory canal, ear drum, ossicles Causes -Infection -Inflammation -Foreign body -Trauma -CX- Meningitis from initial infection TX: -Heat -Antibiotics -Ear drops, ointments, -Irrigation -Surgery -Hearing aids
S/S:
Depends on severity - Loss of motor and sensory fn - Pain - Weakness - Flaccid paralysis - Burning sensation -Cold phase vs. warm phase --WARM: extremity is warm, skin is flushed or rosy --COLD: After 2-3weeks, color is cyanotic, mottled, or red/blue, and feels cold
Care of a pt w/ Meningitis Pg 865 Chart 42-9
EDUCATION - Prevent with Vaccination (give 1x at 11-12 y/o and a booster Q16 years) - Vaccine recommended for anyone in a shared residence, traveling, or immunocompromised - Safe to give a booster 8 weeks after vaccine - Handwashing INTERVENTIONS: - Handwashing - Standard Precautions - Droplet Precautions with bacterial meningitis (Mask, Gown, Gloves) - Neuro checks Q4h (Neuro changes important to indicate) - Vascular Check Q4h or sooner if indicated - Cranial Nerve Testing (CN III,IV,VI,VII, VIII) ---Important to test because a VI CN defect indicate hydrocephalus MEDS: - Broad spectrum antibiotic is started and then specific antibiotic after C&S - Usually a 2 week course of tx -Mannitol for increase ICP -Antiepileptic drugs - Steroids -PROPHYLAXIS (for people who were in close contact w/ infected pt) ---Rifampin, Ciprofloxacin, or Ceftriaxone
Assessment of Balance
ELECTRONYSTAGMOGRAPHY (ENG) - Electrodes used and if pt fails to have nystagmus it indicates that there is an abnormality in the vesticulocochlear apparatus - NPO for hrs before the test, and no caffeine for 24-48hrs - No Pacemakers allowed CALORIC TESTING - Water or air that is warmer or cooler than the body is inserted to the pts ear-- they should have vertigo or nystagmus w/in 20-30 secs - NPO before and bed rest after RHOMBERG TEST - Monitor the degree of swaying of the patient with their eyes closed and their hands at their sides.
Using Eyedrops/ Instillation of eyedrops Pg. 970, Chart 46-2 Pg 975, Chart 46-3
EYE DROPS: -Apply in the lower conjunctiva and do not touch eye -Equipment must be sterile -Hand washing before insertion -Do not allow dropper to touch the eye -Do not allo drops from 1 eye to flow to next -Tilt head back -Place drops in lower conjunctival sac -Instruct client not to squeeze eye -Ok to blink between drops -To prevent systemic re-absorption - press the inner angle of the eye EYE OINTMENT: -Insert starting from inner canthus all the way out
EXAM: CN Know fn, how to test them (Pg 835, Table 41-3 and Kaplan Pg 335)
Exam questions aked in a scenario based i.e. The pts shoulder cannot move, what CN? Pt cannot swallow, what CN? If we need to test the pts auditory fn, how do we do it?
Trauma
Foreign Bodies -Eyelashes, dirt, airborne substances, etc. - Examined with fluorecein - Use irrigation w/ NS to remove Lacerations - Sharp objects - Eyelids and cornea most affected - Tx: Icepack, sutures in ER, Corneal lacerations are EMERGENCY and may require corneal transplant or enucleation Penetrating Injuries -Ususally leads to perm loss of vision - Usually from high speed glass, wood, BB pellets, etc - MRI CONTRAINDICATED if injury is metal Hyphema - Collection of blood inside the front part of the eye Contusion TV and reading restricted in these conditions *Do NOT remove objects from pts eyes, surgeon does this*
Community based Care Pg 890, Chart 43-5
HOME CARE - Open surgeries are activity restricted for 3-6 mos, may return to work w/ restrictions after 6 weeks - MIS normal activities a few days to 3 weeks post op SELF MGMT - Body Mechanics and Strengthening (refer to Chart 43-5) - Stop Smoking - Wt reduction - Take meds - Failed Back Surgery Syndrome may occur (Pain mx is key for this and spinal cord stimulation can be used to control pain) ---Assess pts with this device frequently and below the insertion site (epidural space) and report any neurological changes ASAP
Cranial Nerves
III, IV, VI= Muscle around the eye II= optic nerve for sight V= blink reflex VII= lacrimal glands and muscles for lid closure
EXAM: Stages of Parkinson Pg 867, Table 42-3
Know How to HELP the pt in each of these stages
Surgical mgmt of Glaucoma (only used when meds ineffective)
LASER TRABECULOPLASTY ---Burns the trabecular causing scarring of the meshwork fibers, causing them to tighten and thus increasing the outflow of aqeous humor and decreased IOP VISCOCANALOSTOMY WITH SHUNT ---Small tube implanted and fluid flows through and around the tube into a flat plate that is surgically placed. CLOSED ANGLE --Surgery creates an opening to release pressure
Entropion
Lid goes inward
Ectropion
Lid goes outward
Dx for Meningitis
Lumbar Puncture -CSF analyzed for cell count, differential count, and protein - C&S also done - >60 y/o a CT is usually done before CSF Counterimmunoelectrophoresis (CIE) - Tests for the viruses and protozoa CBC - Increase in WBC ELECTROLYTES - Na will be low X RAY, CT MRI - Identify abscess and hydrocephalus
Nonsurgical mgmt of Glaucoma
MEDICATIONS - They do not improve loss of vision, but only prevent more damage by decrease IOP - Decrease amt of fluid and decrease pressure - Increases the out flow of the duct - TAKE MEDS FOREVER w/ open angle - MEDS FOR OPEN ANGLE INCLUDE PO GLYCERIN AND IV MANNITOL
TX for Hearing loss
NONSURGICAL - Early Detection - Drugs i.e. antibiotics for infection - Assistive Devices i.e. Portable Amplifiers for phone and TV, Light that comes up when the doorbell rings, HEARING AID SURGICAL - Cochlear implantation (superficial surgical procedure) ---Three components of the device: a sound processro, sensor, and a computer ---Not covered by insurance - Tympanoplasty (reconstruction of eardrum- Myringoplasty OR replacement of the ossicles- Ossiculoplasty) ----POST OP: Antiseptic soaked gauze is packed in the ear, dressing over is incision, PT POSITION is flat, with the head turned to the side and operative side facing up for at least 12h post op - Stapedectomy ---POST OP: Hearing does not improve until 6 wks post op, Assess for damage of CN VII,VIII,X (assymetry in face, taste alterations)
Interventions
NONSURGICAL - PREVENT ASPIRATION and SAFETY #1 - ROM - ADLs (Self care as much as possible on their own-- OT) - Sleep patterns - Diets (Ca, Vit K, and nutrients) ---Thickened fluid "Thick It", soft diet (SLP evaluate swallowing) ---Small, frequent meals ---Elevate HOB to prevent aspiration ---TPN may eventually be needed - Yoga, Tai Chi - Alternative communication of pt cannot speak - Psychosocial support SURGICAL: - Stereotactic pallidotomy/Thalamotomy: ---Burr hole is made & rod is inserted into targeted area and electrical stimulation is given ---Goal is for reduction in rigidity & muscle tremor ---Thalamotomy: opening into thalamus - high frequency current destroys tissue, Most affected side done only ---Electrode inserted into thalamus, connected to a pulse generator and delivers electrical current to tremor cells -Deep brain stimulation: ---Electrodes are implanted into the brain and connected to a small electrical device called pulse generator - Fetal Tissue Transplantation ---Experimental
Dx of Bells Palsy
No specific test - Look like they had a stroke -VII cranial nerve check -CT / MRI
EXAM: Cataract surgery (Outpt)
PREOP -Give accurate information - informed consent -Assess how patient's vision affect ADLs -Anticoagulants - may need to be stopped i.e. ASA and Coumadin INTRAOP -Lens is taken out via phacoemulsification - May have an IV infusion -Sedative -Eyedrops to dilate & local anesthetic to paralyze lens POSTOP - Visual improvement almost immediately (some pts return to 20/20) -Eye drops instilled in a specific schedule - Wear sunglasses in light until pupil constricts again - Activity restrictions to prevent increase in IOP - Mild itching normal - Bloodshot normal - Slight lid swelling normal -Cool compress can be used - Creamy, white, crusty drainage normal - Eye patch while sleeping - cooking and light housework okay (no vacuuming) -Avoid straining, no heavy lifting - Bend from knees only
Cerebral Blood Flow Evaluation
Particularly useful in evaluating cerebral vasospasms
Optic Disc
Pink or white depressed area where the nerve fibers synapse with photoreceptors to form the optic nerve
Balance
Propioception
TX for Encephalitis
RN CARE: -Provide supportive care (rest, nutrition, fluids) to help the body fight the infection, and to relieve symptoms -Reorientation and emotional support for confused or delirious people may be helpful - Delegate to UAP to have pt deep breathe and cough - HOB 30-45 degrees - Safety Measures - Neuro Checks Q2h-- observe for change in LOC ---In coma pts, check VS and pupils -ABCs (patent airway, prevent atelectasis, pna) - EEG -EDUCATION: ---Protect self from mosquitos in infested areas --- -Physical therapy and speech therapy if needed MEDS: -Antiviral medications i.e. acyclovir (Zovirax) and foscarnet (Foscavir) ---Treat herpes encephalitis or other severe viral infections (however, no specific antiviral drugs are available to fight encephalitis) -Antibiotics -- if the infection is caused by certain bacteria may be needed after the illness is controlled -Anti-seizure medications (such as phenytoin) -- to prevent seizures -Steroids (such as dexamethasone) -- to reduce brain swelling (in rare cases) controversial -Sedatives -- to treat irritability or restlessness -Acetaminophen -- for fever and headache
Ways to Improve Communication Pg 877, Chart 42-14
SLP Works with them on: -Aphasia [difficulty speaking and understanding language] -Anomia [difficulty finding words to name an object] -Apraxia [ difficulty recognizing words]
Visual Acuity
SNELLEN CHART - Distance vision test - Pt reads at 20 ft away what they are able i.e. Pt is able to do 20/50, they are reading at 20 feet away, what a normal sighted person would read at 50 ft - If pt cannot see from 20/400, do the finger test= at 5 ft away how many fingers holding up - If pt cannot do finger test, then do Hand Motion test where you stand 2-3 ft away and ask what hand is doing - If they cant do that then for Light Perception test where pt covers one eye at a time and you stand 2-3 ft away and pt tells you when you turn the penlight on or off ROSENBAUM POCKET VISION SCREENER or JAEGER CARD - Small hand-held mini eye chart VISUAL FIELD - Confrontation Test - Perimetry (computerized test) EOM - Six cardinal positions - Nystagmus normal w/ lateral gaze ISHIHARA CHART - Tests color vision
Community Based Cre
Self Care needs - OT adaptive devices - Remove all hazards from home incld ovens and cover outlets - Seizure education - Dietician collab - Exercise program - Teach famly meds - Healthcare Resources
CSF
Should be Clear, colorless -A, Normal crystal-clear CSF. -B, Blood in the CSF, which could result from a traumatic (bloody) tap or from subarachnoid hemorrhage. In a traumatic tap, subsequent tubes of CSF are usually less bloody. -C, Centrifuged CSF in a traumatic tap. The supernatant is nearly clear. -D, CSF from a patient with subarachnoid hemorrhage. There is blood at the bottom of the tube and the supernatant is yellow (xanthochromic) as a result of breakdown of blood cells in the CSF before the lumbar puncture.
EXAM: Medications for Glaucoma Pg 988, Chart 47-6
TEACHINGS: - PUNCTAL OCCLUSION NEEDED to prevent drop from leaving eye and put pt at risk for systemic absorption ---Place finger to the end of the eye so the meds don't get absorbed) - Instill gtts as Rx!! Need to be on time - If > 1 gtt, wait 5-10 mins in between gtts to prevent washing out - Keep eye drop tip clean SOME MEDS: -Prostaglandin Agonists (*prosts) ---Dilate blood vessels, eyes darken, longer eyelashes -Adrenergic Agonists (*ine) ---Dilate pupils, wear dark glassess outside -Beta Adrenergic Blockers (*lols) ---Block beta adrenergic receptor in the eye ---Ask if client has severe asthma or COPD -Cholinergic Agonists ---Decrease amount of aqueous humor (miosis/pupils smaller) ---Report increased salivation or drooling to HCP ---May be harder to see in dim light d/t miosis -Carbonic Anhydrase Inhibitors(*mides) ---Allergy to sulfa
EXAM: Crises Associated with MG Pg 920, Table 44-1
TENSILON crisis -Atropine sulfate CHOLINERGIC crisis - Caused by too many anticholinergic drugs (meds) -Maintain respiratory function -Anticholinergic drugs withheld while on ventilator because it makes secretions thick leading to poor O2 - Tesilon provides NO improvement in this crisis - Atropine can be given MYASTHENIC crisis - An exacerbation or flare up of MG S/S - Caused by infection NOT drugs - Tensilon provides temp improvement in this crisis -Maintain RESPIRATORY function #1 -Cholinesterase-inhibiting drugs withheld
CONDITIONS AFFECTING INTERNAL EAR
TINNITUS - Continuous ringing or noise perception in the ear - Goes from mild to severe - Can be caused by other factors i.e. menieres, ASA, NSAIDS, some diuretics VERTIGO AND DIZZINESS -Vertigo is a real sense if whirling or turning in space -Dizziness is a disturbed sense of a person's relationship to space -S/S: ---Nausea, vomiting, falling, nystagmus, hearing loss, tinnitus -Teaching: ---Change position slowly ---Hydration (especially after vomiting) ---Maintain a safe, uncluttered environment ---Take meds that decrease vertigo -Meds: ---OTC= Dramamine, Gravol ---Prescription= Valium (diazepam), Antivert (meclizine), ---Transderm Scop (scopolomine) ---Avoid operating machinery or driving while taking these drugs LABYRINTHITIS - An infection of the labyrinth that causes an erosion of the bony capsule. -Often due to cholesteatoma which is a benign over growth of squamous cell epithelium. -Can follow a middle ear infection as a complication -Often viral in origin and may occur with an URI or mononucleosis -S/S: ---Hearing loss, tinnitus, nystagmus to the affected side, and vertigo with N&V. -Complication: Meningitis -TX: ---Self limiting with treatment. ---Rest in darkened rooms ---Antibiotics, antiemetics, antivertigi drugs help relieve symptoms MENIERE'S DISEASE (EXAM) -Three main features --1) Tinnitus --2) One sided sensorineural ausitory snesory perception loss --3) Vertigo -Rare neurological disorder - recurrent attacks of vertigo with sensorineural hearing loss - Has points of remission and exacerbation -Possibly due to degeneration of the cochlear hair cells of the labyrinth OR an excess of endolymphatic fluid that distorts the entire inner-ear canal system (damaged cochlea) S&S -N&V - Conduction Hearing Loss (From outside of the ear to the tympanic membrane) - Sensory Hearing Loss (From tympanic membrane inward)-- Can lead to nerve damage -Incapacitating vertigo -Tinnitus -Feeling of pressure/fullness in the ear -Fluctuating of hearing loss (deaf after repeated episodes) -Nystagmus -Attacks can occur several x a week/ periods of remission for several years TX: -Bedrest during acute phase -Provide protection when ambulatory -EXAM: Maintain adequate nutrition- drink H2O consistently throughout day, low Na diet, avoid MSG, caffeine, nicotine (no smoking) & alcohol -Salt-free & neutral ash (Furstenberg diet), restrict water & salt --Slow down movements, pull over if driving, occupational counseling - MEDS: Mild diuretic, nicotonic acid, antihistamine, and antivertigo drugs -SURGERY: --Decompression with Teflon shunt for continuous drainage --Total labyrinthectomy (loss of hearing) --Meniett Device- low pressure micropulses displaces inner ear fluid -Surgery often causes loss of hearing in the affected ear ACOUSTIC NEUROMA -Benign Tumor of 8th cranial nerve. -Damages other structures as it grows. S/S -Deafness - partial initially -Twitching, grimacing of facial muscles -Dizziness and Tinnitus DX - CT or MRI TX: - Craniotomy for excision of tumor. Difficulty with preserving facial nerve (VII)
Dx Tests for Glaucoma
TONOMETRY - Open: 22-32 - Close: >32 VISUAL FIELD GONIOSCOPY OPTIC NERVE IMAGES
Refractive Disorders
TX: - Specs, Cls - LASIK (Laser in-situ keratomileusis) ---Superficial layer of cornea is lifted and laser reshaped the deeper layers and then the flap is replaced ---Complications: infection, dry eyes, cloudy cornea, refractive errors ---Corrects hyperopia, myopia, and astigmatism ---Usually both eyes at same time
Middle Ear
Tympanic membrane (pearly gray in color). Conducts sound vibrations from the external ear to the inner ear.
Which CN is responsible for hearing and balance?
VIII
General Tests for the Ear
VOICE TEST - Whisper test AUDIOSCOPY - Handheld device that generates tones of varying intensities TUNING FORK - To determine if it conductive or sensorineural hearing loss --WEBER: Vibrating tuning fork placed in the middle of the head and pt indicates if sound is heard equally or louder in one ear (LATERALIZATION is the term if it is heard louder in one ear) --RINNE: tests air vs bone; air is usually heard 2-3 TIMES LONGER than bone ----Start with fork on mastoid and once the don't hear it, move to the front by the pinna
Protection from the West Nile Virus Pg 866, Chart 42-10
West Nile Virus dx with CSF or blood- contains IgM
External Ear
auricle or pinna, tragus, mastoid process
Eustachian Tube- or auditory tube
connects the middle ear with the nasopharynx
External auditory meatus (Canal)
contains cerumen (yellow, brown, or grey)
Inner Ear
contains the bony labyrinth . The vestibule and the three semicircular canals are responsible for equilibrium
Dx for HD
family history, clinical assessment, genetic testing (dominant inheritance), choreoathetosis (neuromuscular symptoms), & dementia