NSG-320 Exam 4

Humira

-Biologic response modifier -Used to treat rheumatoid arthritis Patient Teaching for Self Administration (Subcutaneous): -Store in refrigerator -If you miss a dose of this medicine, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. -Do not double doses. -Protect the medicine from direct light -Monitor patients closely for signs and symptoms of infection during and after treatment

mixed dementia

-2 or more types of dementia present at the same time -Hallmark abnormalities of Alzheimer's disease + another type of dementia -Usually vascular dementia

methotrexate

-A DMARD -Used early on in rheumatoid arthritis to slow the progression -Lower risk for toxicity -Rare side effects of bone marrow suppression and hepatotoxicity -Frequent lab monitoring for CBC, CMP -Starts to work within 4-6 weeks -Given with other DMARDs or biologic response modifiers (such as corticosteroids) if it doesn't provide adequate relief Nutrition: -Loss of appetite -Fatigue & decreased mobility & endurance makes food shopping and preparation difficult -Collaboration with nutritionist -Occupational therapy can help modify the home environment

fracture

-A break or disruption in the continuity of a bone that often affects mobility and sensory perception. -The primary cause of is trauma from a motor vehicle accident or fall, especially in older adults -Classified by the extent of the break as complete or incomplete -Described by the extent of associated soft-tissue damage as open (or compound) or closed (or simple) -Older adults are at risk for compression fractures (spontaneous, osteoporosis) -Sports, vigorous exercise, and malnutrition are contributing factors. -Bone diseases, such as osteoporosis, increase the risk of a fracture in older adults. -In young, healthy adult bone, healing takes about 4 to 6 weeks. -In the older person who has reduced bone mass and density, healing time is lengthened; complete healing often takes 3 to 6 months. -Factors that affect healing include the severity of the trauma, the type of bone injured, type of management, infections, and ischemic or avascular necrosis. Interprofessional Collaboration: -Closed reduction: cast or splint; most common nonsurgical methods for managing a simple fracture; splint initially applied to keep bone in alignment; once the swelling has decreased, a cast is placed -Traction: bucks, skeletal (external fixation devices) -Surgical: open reduction and internal fixation (ORIF), external fixation devices, hip replacements Cast Care: -Immobilize -PRICE: Protection, Rest, Ice, Compression, Elevation Cast Care Client Education: -Focuses on getting them ready to get a cast, how to look after the cast at home, and what to do after the cast comes off -Call your doctor right away if: -You have increased or severe pain. -You feel a warm or painful spot under the cast. -You have problems with your cast. For example: -The skin under the cast burns or stings, the cast feels too tight. -There is a lot of swelling near the cast. (Some swelling is normal.) -You have a new fever. -There is drainage or a bad smell coming from the cast. -Your foot or hand is cool or pale or changes color. -You have numbness or tingling in your arms, fingers or toes. -You have trouble moving your fingers or toes. -You have symptoms of a blood clot in your arm or leg. (This is called a deep vein thrombosis.) Symptoms may include: pain in the arm, calf, back of the knee, thigh, or groin; redness and swelling in the arm, leg, or groin -Watch closely for changes in your health, and be sure to contact your doctor if: -The cast is breaking apart. -You are not getting better as expected.

osteoporosis

-A chronic metabolic disease in which bone loss causes decreased density and increases the risk of fracture -Often referred to as a silent thief, the first indication in most people occurs as a fracture, often of the hip, spine, or wrist. -Most patients are unaware that they have it until they experience a fracture, the most common complication of the disease. -It and osteopenia (low bone mass) occur when bone resorption activity is greater than bone-building activity. -It is caused by a combination of genetic, lifestyle, and environmental factors. Risk Factors: -Older age -Female -Low body weight -White & Asian ethnicity -Smoker -Sedentary (lack of physical exercise) -Estrogen deficiency -Family history -Chronic low calcium or vitamin D (osteomalacia) -High alcohol intake -Low testosterone in men -Long term corticosteroid use -Drinking over 40 ounces of carbonated beverages each day Clinical Manifestations: -Back pain, restrictive movements, loss of height -Dowager's hump (kyphosis of the dorsal spine) -Risk of fractures-radius and femur/hip Diagnostic Testing: -Bone mineral density (BMD) -Osteoporosis = T-score < -2.5 -Serum calcium, vitamin D, and ALP Nursing Interventions: -Nutrition -Physical activity -Medication: biophosphonates (Alendronate); raloxifene (Evista) mimics estrogen without stimulation of breast or uterus -Kyphoplasty -Educate the patient and family on home safety

Parkinson's disease

-A chronic, progressive neurodegenerative disorder characterized by slowness in the initiation and execution of movement, increased muscle tone (rigidity), tremor at rest, and gait disturbance -The most common form of Parkinsonism (a syndrome characterized by similar symptoms) Clinical Manifestations: -Tremor -Rigidity -Bradykinesia, hypokinesia, or akinesia -Postural instability -Depression -Dementia -Sleep disturbances -Difficulty smelling Complications: -Dysphagia may result in malnutrition or aspiration -General debilitation may lead to pneumonia, UTIs, and skin breakdown -Orthostatic hypotension: ↑ risk for falls and injuries (the patient's increased fall risk increases the need for the primary caregiver to be aware of environmental conditions that may also contribute to falls) Health History: -Fatigue -Excessive salivation -Dysphagia -Weight loss -Constipation -Incontinence -Difficulty initiating movements, falls -Loss of dexterity -Diffuse pain in head, shoulders, neck, back, legs, and hips -Insomnia -Depression -Mood swings Clinical Manifestations: -Blank faces, infrequent blinking -Seborrhea -Dandruff -Ankle edema -Postural hypotension -Tremor at rest: aggravated with anxiety; absent in sleep -"Pill rolling" -Poor coordination -Cognitive impairment and dementia -Impaired postural reflexes -Cogwheel rigidity -Dysarthria -Bradykinesia -Contractures -Stooped posture -Shuffling gait Planning/Goals: -Maximize neurologic function -Maintain independence in activities of daily living (ADLs) for as long as possible -Optimize psychosocial well-being Diagnostic Tests: -No specific tests exist -Diagnosis based on history and clinical features: •Requires presence of trap •Asymmetric onset •Confirmation is a positive response to antiparkinsonian drugs -Clinical diagnosis requires the presence of TRAP and asymmetric onset. T - tremors at rest R - cogwheel rigidity of limbs and movement A - akinesia or bradykinesia, slowing of movements P - postural instability, clumsy, shuffling gait Interprofessional Care: -No cure for PD -Interprofession al care is aimed at symptom management -Antiparkinsonia n drug therapy either: •Aimed at correcting imbalances of neurotransmitters within the CNS •Enhance or release supply of dopamine •Antagonize or block the effects of overactive cholinergic neurons in the striatum -Surgical therapy: •Used in patients unresponsive to drug therapy or who have developed severe motor complications •DBS - deep brain stimulation •Ablation - destruction •Transplantation Drug Therapy: -Levodopa with carbidopa (sinemet) is the primary treatment -Precursor of dopamine -Can cross blood-brain barrier -Converted to dopamine in the basal ganglia -Carbidopa inhibits an enzyme that breaks down levodopa before it reaches brain -The combination of levodopa and carbidopa is that more levodopa reaches the brain, and therefore less drug is needed. -Has many side effects and drug interactions. -Prolonged use often results in dyskinesia (abnormal or impaired voluntary movement) and "off/on" periods when the medication will unpredictably start or stop working. -Effects may be delayed for several weeks to months. -Monitor for signs of dyskinesia: report any uncontrolled movement of face, eyelids, mouth, tongue, arms, hands, or legs; mental changes; palpitations; severe nausea and vomiting; difficulty urinating -Use of only one drug is preferred (fewer side effects, dosages are easier to adjust); combination therapy is often required as disease progresses -Rotigotine (Neupro), another dopamine receptor agonist, is a transdermal patch applied once daily as an adjunctive therapy for patients taking Sinemet. Deep Brain Stimulator: -Most common surgical treatment -Reversible and programmed to deliver a specific current to the targeted brain location -Increased neuronal activity produced by dopamine depletion -Improves motor function -Reduces dyskinesia and medications -DBS involves placing an electrode in the thalamus, globus pallidus, or subthalamic nucleus and connecting it to a generator placed in the upper chest (like a pacemaker). -DBS is preferred to ablation procedures because it is reversible and programmable, and can be safely performed bilaterally. -DBS procedures reduce the increased neuronal activity produced by DA depletion. -It has been shown to improve motor function and reduce dyskinesia and medication usage. -DBS is most effective when candidates are carefully selected and screened. Interprofessional Care: -Ablation Surgery: •Locate, target, destroy area of brain affected by PD •Destroys tissue that produces abnormal chemical or electrical impulses leading to tremors or other symptoms •Typical targets of ablation are the thalamus (thalamotomy), globus pallidus (pallidotomy), and subthalamic nucleus (subthalamic nucleotomy). -Transplantation of fetal neural tissue into the basal ganglia: •Provides dopamine-producing cells in the brains of patients •Research and clinical trials are ongoing Nutritional Therapy: -Malnutrition and constipation can be serious consequences -Patients with dysphagia and bradykinesia need food that is easily chewed and swallowed -Adequate fiber to avoid constipation -Eating more numerous small meals is less exhausting than eating fewer large meals each day -Cut food into bite-sized pieces before it is served, and serve it on a warmed plate to preserve its appeal. -Provide ample time to avoid frustration -Levodopa can be impaired by protein and vitamin b6 ingestion Nursing Implementation: -Maintenance of good health -Encouragement of independence -Avoidance of complications such as contractures and falls -Promote physical exercise and a well balanced diet -Limit consequences from decreased mobility such as muscle atrophy, contractures, and constipation -Problems secondary to bradykinesia can be alleviated by: •Consciously thinking about stepping over a line on the floor •Lifting toes when stepping •One step back and two steps forward -A physical therapist may be consulted to design a personal exercise program aimed at strengthening and stretching specific muscles. -Overall muscle tone and specific exercises to strengthen the muscles involved with speaking and swallowing should be included. -Although exercise will not halt the progress of the disease, it will enhance the patient's functional ability. -An occupational therapist can also assist the patient with strategies to increase self-care measures, including eating and dressing. -Get out of a chair by using arms and placing the back legs on small blocks -Remove rugs and excess furniture -Simplify clothing from buttons and hooks by the use of slip-on shoes and Velcro hook-and-loop fasteners or zippers on clothing -Use elevated toilet seats -Use an ottoman to elevate legs and help avoid dependent ankle edema -Manage sleep problems; some patients find the use of satin nightwear and/or satin sheets beneficial -Assist patients as they make adjustments to their lifestyle to accommodate symptoms -Caregivers may experience stress associated with disease progression (i.e., dementia) -Ensure that the patient with PD receives prescribed medications on time to avoid on-off effects Expected Outcomes: -Experience safe passage of fluids and/or solids from mouth to stomach -Use methods of communication that meet needs for interaction with others -Perform physical exercise to deter muscle atrophy and joint contractures -Use assistive devices appropriately for ambulation and mobility -Maintain nutritional intake adequate for metabolic needs

multiple sclerosis

-A chronic, progressive, degenerative disorder of the CNS characterized by disseminated demyelination of nerve fibers of the brain and spinal cord. -Cause is unknown -Develops in a genetically susceptible person as a result of environmental exposure, like an infection. -Multiple genes are believed to be involved in the inherited susceptibility and first-, second-, and third-degree relatives of patients with the disorder are at an increased risk. -Possible precipitating factors include infection, smoking, physical injury, emotional stress, excessive fatigue, pregnancy, and a poor state of health -The primary neuropathologic condition is an autoimmune process orchestrated by activated T cells (lymphocytes) -Three pathologic processes characterize it: chronic inflammation, demyelination, and gliosis (scarring) in the CNS -Exacerbations are triggered by infection (especially upper respiratory and urinary tract infection) Risk Factors: -Smokers -Type I diabetics -Thyroid -Irritable bowel syndrome Clinical Manifestations: -Onset of the disease is often insidious and gradual -Vague symptoms occur intermittently over months or years, not enough to seek medical attention -Disease diagnosed long after onset of 1st symptoms -Chronic, progressive deterioration in some patients -Remissions and exacerbations in others -Overall trend is progressive deterioration in neurologic function -Symptoms vary according to areas of CNS involved -Some have severe, long-lasting symptoms early in disease -Others have occasional and mild symptoms for several years -Severe fatigue -Tremors -Bladder and bowel dysfunction -C/o pain in low thoracic area or abdominal region. -Decrease peripheral sensation (pain, temperature, touch) -Emotional instability -Speech impediments -Cognitive functions -Visual disturbances: blurred or double vision, blindness -Spasticity of muscles: affects walking and standing, partial or complete paralysis -Dizziness -Hearing loss -Dysphagia Interprofessional Management: -No cure - supportive therapy -Energy conservation -Maintain adequate fluid intake (2000 ml/day) -Provide bowel and bladder training -Encourage activity independence -Regulate temperatures on water heaters, baths, and heating pads -Home safety (rugs, cords, etc.) -Drug therapy Glatiramer Acetate (copaxone): -Immunomodula tor for muscular sclerosis -Education: •Instructions about giving the sq injections -Reporting side effects: •Inj-site: hives, rash, irritation, severe pain, flushing, chest pain •Allergic reaction: itching, trouble breathing, chest pain, dizziness, sweating •Do not change dosing or stop taking product without HCP advice Nursing Interventions: -Help patient identify triggers and develop ways to avoid them or minimize their effects -Reassure patient during diagnostic phase -Assist patient in dealing with anxiety and grief caused by diagnosis -During acute exacerbation, prevent major complications of immobility -Focus teaching on building general resistance to illness: avoid fatigue, extremes of hot and cold, exposure to infection Client Education: -Self-catheterization if necessary -Adequate intake of fiber to aid in regular bowel habits -Emotional adjustments -Lifestyle changes -Good balance of exercise and rest -Minimize caffeine intake -Nutritious, well-balanced meals: increase fiber if constipated -Treatment regimen: management of medications -The patient should know the treatment regimens, drug side effects, how to identify and manage side effects, and drug interactions with over-the-counter medications. -The patient should consult a HCP before taking nonprescription drugs. -Bladder control is a major problem for many patients. -Although anticholinergics may be beneficial for some patients to decrease spasticity, you may need to teach others self-catheterization. -Bowel problems, particularly constipation, occur frequently in patients. Increasing the dietary fiber intake may help some patients achieve regularity in bowel elimination. -The patient with MS and the caregiver need to make many emotional adjustments because of the unpredictability of the disease, need for lifestyle changes, and challenge of avoiding or decreasing precipitating factors. -The National Multiple Sclerosis Society and its local chapters can offer a variety of services to meet the needs of patients with MS. Expected Outcomes: -Maintain or improve muscle strength and mobility -Use assistive devices appropriately for ambulation and mobility -Maintain urinary continence -Make decisions about lifestyle modifications to manage it

gout

-Acute form of arthritis -Tophi: bone erosion, occurs with the chronic form of the disease -Primary: hereditary error of purine metabolism (↑production) -Secondary: caused by other diseases or medications Risk Factors: -Obesity -Intake of red & organ meat, shellfish, fructose -ETOH abuse -Prolonged fasting -Medications: thiazide diuretics, beta blockers, ACE inhibitors, aspirin, niacin, immunosuppressives for transplants -Diseases: diabetes, hyperlipidemia, hypertension, atherosclerosis, renal insufficiency, sickle cell anemia Diagnostics: -Serum uric acid >6mg/dL -24hr urine collection (from decreased excretion vs. ↑production), - -Synovial fluid tests -X-ray

cerebral vascular accidents

-Also known as strokes Two Main Types: ●Ischemic ○Blood vessel is blocked off ○Lack of oxygen & nutrients ○Thrombotic: the process of clot formation (thrombosis) results in a narrowing of the lumen, which blocks the passage of blood through the artery ○Embolic: an embolus is a blood clot or other debris circulating in the blood; when an embolus reaches an artery in the brain that is too narrow to pass through, it lodges there and blocks the flow of blood ●Hemorrhagic ○Bleeding into the brain tissue ○Causes pressure increases (ICP) ○Lack of oxygen & nutrients ○Intracerebral - bleeding in the brain, usually a ruptured vessel ○Subarachnoid - bleeding in the CSF space between the pia matter and arachnoid space, usually an aneurysm Risk Factors: -Hypertension -Heart disease -Diabetes -Smoking -Obesity -Sleep apnea -Metabolic syndrome -Lack of activity/exercise -Poor diet -Drug & ETOH abuse -Genetics -Age -Gender -Ethnicity of African American, Hispanic, Native American, and Asian American General Signs and Symptoms: -Decreased consciousness -Severe headache -Drooping eyelid and mouth on one side of the face -Paralysis or weakness on one or both sides of the body -Arm drift -Loss of bowel or bladder control -Change in personality -Pupils unequal in size -Loss of vision, dimness, or double vision -Difficulty speaking or slurred speech -Inability to speak -Nausea or vomiting -Sudden weakness or paralysis of the face, arm, or leg -Possible seizures -Aphasia occurs when stroke damages dominant hemisphere of brain and affects language ○Receptive - loss of comprehension ○Expressive - loss of production of language ○Global - total inability to communicate -Dysphasia refers to impaired ability to communicate -Used interchangeably with aphasia -Nonfluent: Minimal speech activity with slow speech -Fluent: Speech is present but contains little meaningful communication -Many patients experience dysarthria: disturbance in muscular control of speech -Impairments may involve pronunciation, articulation, and phonation -Clients who suffer a stroke may have difficulty controlling their emotions -Emotional responses may be exaggerated or unpredictable -Magnified by: depression, changes in body image, loss of function Clinical Manifestations Determined by Artery Involvement: -Anterior cerebral: motor and/or sensory deficit (contralateral), sucking/rooting reflex, rigidity, gait problems, loss of proprioception & fine touch -Middle cerebral: aphasia, motor and sensory deficit, hemianopsia (dominant side); neglect, motor and sensory deficit, hemianopsia (non-dominant side) -Posterior cerebral: hemianopsia, visual hallucination, spontaneous pain, motor deficit -Vertebral: cranial nerve deficits, diplopia, dizziness, nausea, vomiting, dysarthria, dysphagia, coma Right Brain Stroke Clinical Manifestations: -Paralyzed left side: hemiplegia -Left-sided neglect -Spatial-perceptual deficits -Tends to deny or minimize problems -Rapid performance, short attention span -Impulsive, safety problems -Impaired judgment -Impaired time concepts Left Brain Stroke Clinical Manifestations: -Paralyzed right side: hemiplegia -Impaired speech/ language aphasias -Impaired right/left discrimination -Slow performance, cautious -Aware of deficits: depression, anxiety -Impaired comprehension related to language, math -Agnosia: the inability to recognize an object by sight, touch, or hearing -Apraxia: the inability to carry out learned sequential movements on command Diagnosis: -CT/MRI/MRI Angiography -Blood Flow Studies: ○Cerebral angiography ○Carotid angiography ○Digital subtraction angiography ○Transcutaneous doppler ultrasonography ○Carotid duplex scanning -Cardiac Studies Related to Stroke: ECG, chest X-ray, troponin, CK-MB, echocardiagram -Other labs: ○CBC ○Coagulation (PT/INR, aPTT) ○Electrolytes, blood sugar ○Renal & hepatic labs ○Lipid profile ○CSF Planning/Goals: -Stable/ Improved LOC -Attain max physical functioning -Attain max self-care abilities -Maintain stable body functions -Attain max communication ability -Maintain adequate nutrition -Avoid complications -Maintain effective personal/family coping Nursing Interventions: Acute: -ABCs -Oxygen administration, artificial airway insertion, intubation, and mechanical ventilation may be required. -Call code, call stroke team if in a stroke center -Remove dentures -Take pulse ox reading -After the client is stabilized, treatment focuses on: ○↓ the level of disability ○Attaining optimal functioning -Communication -Sensory & perception alterations -Coping -Ambulatory care -Rehabilitation -Musculoskeletal function & ADLs -Stroke survivorship & coping -Sexual function -Community integration Medical Interventions (Ischemic Stroke): -Measures to prevent development of a thrombus or embolus are used in patients at risk for stroke -Antiplatelet drugs are used in patients who have had a TIA related to atherosclerosis -Aspirin is most frequently used antiplatelet agent -Common dose for aspirin is 81 to 325 mg/day. -Other drugs include ticlopidine (Ticlid), clopidogrel (Plavix), dipyridamole (Persantine), and combined dipyridamole and aspirin (Aggrenox). -For patients who have atrial fibrillation, oral anticoagulation can include warfarin (Coumadin) and the direct factor Xa inhibitors: rivaroxaban (Xarelto), dabigatran (Pradaxa), and apixaban (Eliquis). -The primary advantage of direct factor Xa inhibitors (compared to warfarin) is that these drugs do not need close monitoring or dosage adjustments. -Statins (simvastatin [Zocor], lovastatin [Mevacor]) have also been shown to be effective in the prevention of stroke for individuals who have experienced a TIA in the past. -Recombinant Tissue Plasminogen activator (tPA) ****NEVER USED for HEMMORHAGIC STROKES***** •This is a type of fibrinolytic therapy •Goal: break down the clot by digestion of fibrin & fibrinogen •It must be started within 3-4.5 hours of onset of the first symptoms •Careful screening process - not all clients are candidates to take this •Major risk: hemorrhage leading to death •Usually done at a certified stroke center -Surgeries such as carotid endarterectomy, transluminal angioplasty, and stenting Medical Interventions (Hemorrhagic Stroke): -Hypertension control: systolic <160 -Seizure prophylaxis -Surgery: craniotomy to drain blood & ↓ ICP; clip/coil aneurysm -Ca++ Channel blocker to ↓ vasospasms: nimodipine

Bell's palsy

-An acute peripheral facial paresis of unknown cause. -The most common facial nerve disorder -Characterized by inflammation of the facial nerve (CN VII) on one side of the face in the absence of any other disease such as a stroke -Considered benign -Most patients recover spontaneously within 3 weeks to 9 months -One third of patients may have residual effects of facial weakness, involuntary movements, and persistent tearing of the eye on the affected side -Exact cause unknown -Theory: acute demyelination similar to Guillain-Barre disease -Theory: reactivation of herpes simplex virus isoform and/or herpes zoster virus. The viral infection causes inflammation, leading to nerve compression and clinical features such as facial paralysis. -Theory: other infections Clinical Manifestations: -Bell's phenomenon: an inability to close the eyelid, with an upward movement of the eyeball when closure is attempted, is an inability to smile, frown, or whistle -Unilateral loss of taste is common -Decreased muscle movement may alter chewing ability -Pain behind the ear -Onset is sudden with a rapid onset of unilateral facial weakness that can occur in a few hours. -Many patients have a history of a recent viral illness. -Patients may complain of pain around and behind the ear. -Additional manifestations: •Numbness of the face, tongue, and ear •Tinnitus •Headache •Hearing deficit -Paralysis of the facial nerve resulting in flaccidity of the affected side of the face, with drooling Complications: -Psychologic withdrawal - changes in appearance -Malnutrition -Dehydration -Mucous membrane trauma -Corneal abrasions -Muscle stretching -Facial spasms -Contractures Nursing Interventions: -Pain: analgesics, hot packs for hepatic lesions (aid in circulation) -Hypersensitive to heat and cold: protect face -Risk for aspiration: teach to chew on the unaffected side, avoid trapping food, good oral hygiene -Risk for cornea damage: teach to cover the eye with a protective shield at night, apply eye ointment to keep eyelids closed during sleep. -Muscle tone: show patient how to perform facial massage with gentle upward motion several times daily when the patient can tolerate the massage; demonstrate facial exercises, such as wrinkling the forehead, blowing out the cheeks, and whistling, in an effort to prevent muscle atrophy. -Diet and nutrition: instruct patient to chew on the unaffected side of his mouth; eliminate hot fluids and foods; give frequent mouth care, being particularly careful to remove residues of food that collects between the cheeks and gums

myasthenia gravis

-An autoimmune disease of the neuromuscular junction characterized by the fluctuating weakness of certain skeletal muscle groups -Caused by an autoimmune process in which antibodies attack acetylcholine (ach) receptors, resulting in a decreased number of ach receptor (achr) sites at the neuromuscular junction -This prevents ach molecules from attaching and stimulating muscle contraction -Fluctuating weakness of skeletal muscle -The muscles most often involved are those used for moving the eyes and eyelids, chewing, swallowing, speaking, and breathing -Eyelid muscles or extraocular muscles are involved -Facial mobility and expression can be impaired -The patient may have difficulty chewing and swallowing food. -Speech is affected, and the voice often fades after a long conversation. -The muscles of the trunk and limbs are less often affected. Of these, the proximal muscles of the neck, shoulder, and hip are more often affected than the distal muscles. -No other signs of neural disorder accompany it. There is no sensory loss, reflexes are normal, and muscle atrophy is rare. -Exacerbations can be precipitated by emotional stress, pregnancy, menses, another illness, trauma, temperature extremes, and hypokalemia and certain drugs. -The major complications result from muscle weakness in areas that affect swallowing and breathing; this results in aspiration, respiratory insufficiency, and respiratory tract infection Myasthenic Crisis: -An acute exacerbation of muscle weakness triggered by: •infection •surgery •emotional distress •drug overdose •inadequate drugs Interprofessional Care: -Drug therapy: anticholinesterase agents, corticosteroids, immunosuppressive agents -Surgical therapy: removal of the thymus gland -Other therapies: plasmapheresis, IV immunoglobulin G Nursing Implementation: -Balanced diet that is easily chewed and shallowed (semi-solid foods) -Scheduling doses of drugs so that peak action is reached at mealtime may make eating less difficult. -Arrange diversional activities that require little physical effort and match the patient's interests. -Help the patient plan activities of daily living to avoid fatigue. -Education Focus: the importance of following the medical regimen, complications of the disease, potential adverse reactions to specific drugs, and complications of therapy (crisis conditions) and what to do about them. -Clients admitted to the hospital usually have a respiratory tract infection or are in an acute myasthenic crisis. Nursing care is aimed at maintaining adequate ventilation, continuing drug therapy, and watching for side effects of therapy.

rheumatoid arthritis (RA)

-Common connective tissue disease, destructive to joints -Characterized by natural remissions and exacerbations -Chronic, progressive, systemic, inflammatory autoimmune disease; affects primarily synovial joints -Transformed autoantibodies (rheumatoid factors) form and attack healthy tissue, causing inflammation -Permanent changes may be avoided if diagnosed early -Early and aggressive treatment to suppress synovitis may lead to a remission -Preventing flares helps prevent joint erosion and permanent joint damage. -Because it is a systemic disease, areas of the body besides the synovial joints can be affected. -Inflammatory responses similar to those occurring in synovial tissue may occur in any organ or body system in which connective tissue is prevalent. -If blood vessel involvement (vasculitis) occurs, the organ supplied by that vessel can be affected, leading to eventual failure of the organ or system in late disease Risk Factors: -European Americans -Young to middle-aged women -Female reproductive hormones -Epstein-Barr virus -Physical and emotional stresses Early Manifestations: -Joint inflammation, redness, stiffness, warmth, tenderness, and pain -Low-grade fever -Fatigue -Weakness -Anorexia -Paresthesias Late Manifestations: -Joint deformities (e.g., swan neck or ulnar deviation) -Moderate to severe pain and morning stiffness -Osteoporosis -Severe fatigue -Anemia -Weight loss -Subcutaneous nodules -Peripheral neuropathy -Vasculitis -Pericarditis -Fibrotic lung disease -Sjögren's syndrome -Kidney disease -Felty's syndrome Deformities: -Ulnar drift -Boutonniere deformity -Hallux valgus -Swan neck deformity -Baker's cysts: enlarged popliteal bursae behind the knee, may occur and cause tissue compression and pain -Possible tendon rupture, particularly of the Achilles tendon Diagnostic Tests: -Laboratory: •ESR, CRP •Anti-CPP •Rheumatoid factor •Antinuclear antibody (ANA) -Diagnostic: •Synovial fluid analysis for MMP-3 •X-ray Interprofessional Care: -Drug therapy: •Disease modifying antirheumatic drugs (DMARDs) •Biological response modifiers •Immunosuppressants •Corticosteroids -Nutritional therapy -Physical therapy -Surgical therapy: •Synovectomy - removal of joint lining •Arthroplasty - removal of the diseased joint Nursing Interventions (Chronic Care): -Balance rest & activity -Joint protection -Cold & heat therapy -Exercises -Client and caregiver teaching -Psychological support -Gerontological considerations -Acute care: when clients experience systemic complications or uncontrolled pain

potential complications of fractures

-Compartment syndrome: •6 P's •Fasciotomy -Rhabdomyolysis •CK, CKMM •IV fluids •Monitor creatinine -Hypovolemic shock: •Fluids •PRBCs -Fat embolism -Venous thromboembolism: •SCDs •Lovenox -Osteomyelitis: •WBC •Vital Signs •Long-term Antibiotics -Delayed union: •Surgery/ORIF

epilepsy

-Condition in which a person has spontaneously recurring seizures caused by underlying chronic condition -In United States 3 million people have it -Incidence is increasing in older adults. -There are more than 200,000 new cases diagnosed in the United States each year. -New cases are more common in African Americans and in socially disadvantaged populations. -Males are slightly more likely to develop it than females. -People at high risk to develop it include those with Alzheimer's disease or those who have had a stroke. -The risk is also increased in a person who has a parent who has it

migraine headache

-Described as an intense, throbbing or pounding pain that involves one temple -The pain usually is unilateral (on one side of the head), although it can be bilateral. -Recurring -Premonitory symptoms or triggers such as light, sound, and smell sensitivity -Onset between 20-30 years -Affects 18% of females and 6% of males -State of neuronal hyperexcitability in occipital cortex of the cerebral cortex -May or may not have known precipitating events or factors -Manifestations of migraine are associated with neurologic and autonomic nervous system dysfunction. -Migraine without aura (formerly called common migraine) is the most common type of migraine headache. -Migraine with aura (formerly called classic migraine) occurs in only 10% of migraine headache episodes. Risk Factors: -Family history -Low level of education -Low socioeconomic status -High workload -Frequent tension-type headaches -Migraine is associated with seizure disorders, ischemic stroke, asthma, depression, anxiety, myocardial infarction, Raynaud's syndrome, and irritable bowel syndrome. -In many cases, migraine headaches have no known precipitating events. However, for some patients, specific factors may trigger a headache. These include foods, menstruation, head trauma, physical exertion, fatigue, stress, missed meals, weather, and drugs. Food triggers include chocolate, cheese, oranges, tomatoes, onions, monosodium glutamate, aspartame, and alcohol (particularly red wine). Clinical Manifestations: -Neurologic, psychologic or other premonitory manifestations: may precede the headache phase by several hours or several days; premonitory symptoms may include neurologic (e.g., photophobia), psychologic (e.g., hyperactivity, irritability), and other (e.g., food craving) manifestations. -Aura: a complex of neurologic symptoms that occur before a headache for some patients. It may be characterized by visual symptoms, such as bright lights, scotomas (patchy blindness), visual distortions, or zigzag lines. Sensory (voices or sounds that do not exist, strange smells), and/or motor (e.g., weakness, paralysis, feeling that limbs are moving) phenomena may also be part of an aura. -Steady, throbbing pain: synchronous with pulse, may last 4 to 72 hours -Varies in severity -Although the headache is usually unilateral, it may switch to the opposite side in another episode. -During the headache phase, some patients with migraine may tend to seek shelter from noise, light, odors, people, and problems. Diagnostic Studies: -The diagnosis of migraine headache is usually based on the patient history. The neurologic and other diagnostic examinations are often normal (Table 58-2). -No specific laboratory or radiologic test can diagnose migraine headache. -Neuroimaging techniques (e.g., head computed tomography [CT], with or without contrast, and magnetic resonance imaging [MRI]) are not recommended for routine evaluation of headache unless the neurologic examination reveals abnormal findings. -If atypical features are present, then additional testing is done to rule out a secondary headache. Drug Therapy (Preventive): -Based on frequency, severity, and disability of headaches for each individual -Several different classes of medications are used: antiseizure drugs, botox, SSRIs -Topiramate, an antiseizure drug, may be taken daily for migraine prevention. Common side effects include hypoglycemia, paresthesia, weight loss, and cognitive changes. Usually these side effects are mild to moderate and transient. -Topiramate must be used for 2 to 3 months to determine its effectiveness. Not all patients become pain free on this medication. -HCPs must offer thorough teaching regarding topiramate to promote patient adherence. -Gabapentin (Neurontin) is another antiseizure drug used for migraine prevention. -Botulinum toxin (a Botox) may be an effective prophylactic treatment for patients who have chronic migraines lasting for 4 hours or more at least 15 days each month, or migraines that do not respond to other medications. -Botox is given by multiple injections around the head and neck. Effects last 2 to 4 months; the injections are repeated every 3 months. The most common adverse reactions are neck pain and headache. -A slight risk exists for the toxin to migrate from the injection site to other areas of the face and neck, causing swallowing and breathing difficulties. Teach the patient to seek immediate medical attention if this occurs. -Selective serotonin reuptake inhibitors (e.g., fluoxetine [Prozac]) may also be prescribed. Drug Therapy (Symptomatic): -Mild to moderate headache can obtain relief with NSAID, aspirin, or caffeine-containing combination analgesics -For moderate to severe headaches, triptans have become first line of therapy -Triptans affect selected serotonin receptors -Reduce neurogenic inflammation of cerebral blood vessels -Produce vasoconstriction -They are most effective when taken at the onset of migraine headache or during the aura. -An example of a triptan is sumatriptan (Imitrex). Sumatriptan is available in various forms: oral, subcutaneous, nasal spray, transdermal. -Some patients respond better to one triptan than to others, so HCPs need to be knowledgeable about all of them. -Because these drugs cause vasoconstriction, patients with heart disease or stroke should avoid their use. -The combination drug sumatriptan/naproxen (Treximet) combines a triptan with an antiinflammatory drug. -Risk of serious cardiovascular events such as MI, thromboembolic events, and stroke may increase over time with Treximet. -Zecuity (sumatriptan transdermal system) is the first skin patch indicated for the treatment of migraine headache and for intense nausea secondary to the headache itself. •Zecuity is applied either to the upper arm or thigh. •It should not be applied over red or irritated skin, or over scars, tattoos, or broken skin. •The patient pushes a button to deliver the drug through the skin over a course of 4 hours. •Zecuity has similar contraindications to other triptans. •When triptans are contraindicated or ineffective, other drugs can be used (See Table 58-1).

cluster headache

-Focused in and around one eye and is often described as sharp, penetrating, or burning. -Most severe primary headache -Generally occur at same time of day or night -Onset between 20-45 years -Men affected 3x more often than women -Triggers can include: alcohol, strong odors, weather changes -Neither the cause nor the pathophysiologic mechanism is fully known. -The unilateral pain may occur with activation of neurons in the ophthalmic branch of the trigeminal nerve. -They also involve the hypothalamus, with irregularities in melatonin and cortisol. -This indicates a dysfunction of circadian rhythm. -Imaging studies show hypothalamic activation at the onset. Clinical Manifestations: -Sharp, stabbing, intense pain lasts minutes to 3 hours -May occur every other day and as often as 8x/day -Can occur in cycles with remission periods in between -Pain is generally located around the eye, radiating to the temple, forehead, cheek, nose, or gums -Swelling around the eye, lacrimation (tearing), facial flushing or pallor, nasal congestion, and miosis (constriction of the pupil). -Often agitated and restless, unable to sit still or relax -Aura similar to migraine may occur in 14% of patients up to 60 minutes before an attack. -Can occur every other day and as often as eight times a day. -Because they often occur seasonally, headaches may be mistaken for symptoms of allergies. Diagnosed By: -History -CT scan -MRI or magnetic resonance angiography (MRA) may rule out an aneurysm, a tumor, or an infection -Lumbar puncture may rule out other disorders that may cause similar symptoms. -Asking patients to keep a headache diary can be useful. Drug Therapy (Preventive): -High-dose verapamil: the first-choice drug. However, because of its effects on cardiac conduction, verapamil should be only initiated after careful consideration of the risks. Careful monitoring is needed during treatment. -Varied other options such as lithium, ergotamine, antiseizure drugs (e.g., topiramate), and melatonin. -Invasive nerve blocks, deep brain stimulation, and ablative neurosurgical procedures have been used for refractory cluster headaches Drug Therapy (Symptomatic): -Triptans: a gold standard of treatment; either nasal administration or subcutaneous injection is appropriate; are vasoconstrictors and thus contraindicated for patients with vascular risk factors -High-flow 100% oxygen by non-rebreather mask at 6 to 8 L/min for 10 min may relieve headache by causing vasoconstriction and increasing synthesis of serotonin in the central nervous system. -Treatment can be repeated after a 5-minute rest. -Patient must have continuous access to O2 (drawback)

exercises for patients with osteoarthritis or rheumatoid arthritis

-Follow the exercise instructions that have been prescribed specifically for you. There are no universal exercises; your exercises have been specifically tailored to your needs. -Do your exercises on both "good" and "bad" days. Consistency is important. -Respect pain. Reduce the number of repetitions when the inflammation is severe and you have more pain. -Use active rather than active-assist or passive exercise whenever possible. -Do not substitute your normal activities or household tasks for the prescribed exercises. -Avoid resistive exercises when your joints are severely inflamed.

transient ischemic attack (TIA)

-History is associated with an increased risk of stroke -A transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, but without acute infarction of brain -Symptoms typically last < 1 hour -There is no way to predict outcome -It is important to teach the patient to seek treatment for any stroke symptoms, as there is no way to predict if it will resolve or if it is in fact the development of a stroke. -May be due to microemboli that temporarily block the blood flow. -A warning sign of progressive cerebrovascular disease -The signs and symptoms depend on the blood vessel that is involved and the area of the brain that is ischemic. -Should be treated as a medical emergency as it is usually a precursor to ischemic stroke. -Teach people at risk to seek medical attention immediately with any stroke-like symptom and to identify the time of onset of symptoms. -In general, one-third of individuals who experience a TIA will not experience another event, one-third will have additional ones, and one-third will progress to stroke.

vascular dementia (multi-infarct dementia)

-Loss of cognitive function due to brain lesions caused by cardiovascular disease -Ischemic lesions -Hemorrhagic brain lesions -Result of decreased blood supply from narrowing and blocking of arteries that supply brain -Can be caused by a single stroke or by multiple strokes

carotid endarterectomy

-Surgery used to treat cerebral vascular accidents -In a carotid endarterectomy (CEA), the atheromatous lesion is removed from the carotid artery to improve blood flow. -Carotid endarterectomy is performed to prevent impending cerebral infarction. -A tube is inserted above and below the blockage to reroute the blood flow. -Atherosclerotic plaque in the common carotid artery is removed. -Once the artery is stitched closed, the tube can be removed. -A surgeon may also perform the technique without rerouting the blood flow.

dementia

-Neurocognitive disorder with dysfunction or loss of: memory, orientation, attention, language, judgment, reasoning -Other characteristics that can manifest are personality changes and behavioral problems such as agitation, delusions, and hallucinations -Problems ultimately disrupt an individual's work, social responsibilities, family responsibilities, and ability to perform ADLs -The most common cause are neurodegenerative conditions, with the majority of cases being Alzheimer's disease. -Vascular conditions are the second most common cause -Difficult to distinguish etiology on the basis of symptoms alone -Acute or subacute pattern of change may be more indicative of an infectious or metabolic change -Manifestations of different types of dementia overlap -Complicated by coexisting medical issues Clinical Manifestations: -Onset depends on cause -Gradual and progressive over time -Neurologic degeneration -Abrupt -Vascular dementia tends to be abrupt or progress in a stepwise pattern Diagnostic Studies: -Diagnosis is focused on determining the cause -Thorough medical, neurologic, psychologic history, and mental status testing -Rule out other conditions -Neuroimaging techniques -The diagnosis is focused on determining the cause (e.g., reversible versus nonreversible factors). -Screening for cobalamin (vitamin B12) deficiency and hypothyroidism is often performed. -Based on patient history, testing for neurosyphilis may be performed. -Neuroimaging techniques (CT or MRI) may be used to rule out or confirm causes Nursing and Interprofessional Management: -Similar to management and drug therapy of patients with Alzheimer's -Vascular dementia can often be prevented through treatment of risk factors: hypertension, diabetes, smoking, hypercholesterolemia, cardiac dysrhythmias

dementia with Lewy bodies (DLB)

-Neurodegenera tive dementia -Presence of Lewy bodies in brainstem and cortex -Intraneural cytoplasmic inclusions -Features of Parkinson's disease -Medication therapy may assist with symptoms

open reduction internal fixation pre-op focus

-Neurovascular status of affected limb -Vital signs -Pain/spasms -Buck's traction (hip fix) -NPO -Consent -Skin integrity -DVT prevention

tension headache

-Often described as a feeling of a weight in or on the head and/or a band squeezing the head -Most common type of headache -Characterized by bilateral location and pressing/ tightening quality -Usually of mild or moderate intensity and can last from minutes to days -Episodic or chronic -Bilateral frontal-occipital headache described as a constant, dull pressure, or bandlike headache Etiology and Pathophysiology: -Neurologically similar to migraines -Often evolve from episodic to chronic -↑ Frequency not necessarily associated with ↑ intensity -Although the cause is not fully understood, this type of headache is believed to have a neurobiological basis similar to migraine headaches. -Chronic headache can cause diminished quality of life and severe disability. Clinical Manifestations: -Patients often have a bilateral frontal-occipital headache described as a constant, dull pressure, or bandlike headache associated with neck pain and increased tone in the cervical and neck muscles. -The headache may involve sensitivity to light (photophobia) or sound (phonophobia), but does not involve nausea or vomiting. -There are no premonitory symptoms (warning symptoms of impending headache), and physical activity does not aggravate symptoms. -The headaches may occur intermittently for weeks, months, or even years. -Many patients have a combination of migraine and tension-type headaches, with features of both occurring simultaneously. -Patients with migraine headaches may experience tension-type headaches between migraine attacks. Diagnostic Studies: -History -↑ Resistance to passive movement of head -Tenderness of head and neck EMG -Careful history taking may be the most important tool for diagnosing tension-type headache (Table 58-2). -If tension-type headache is present during physical examination, increased resistance to passive movement of the head and tenderness of the head and neck may be present. -Electromyogra phy (EMG) may reveal sustained contraction of the neck, scalp, or facial muscles. -However, many patients may not show increased muscle tension with this test, even when the test is done during an actual headache. Drug Therapy: -Symptomatic: mild-moderate headache treated with aspirin, acetaminophen, or an NSAID alone or in combination with a sedative, muscle relaxant, or tranquilizer -Preventive: tricyclic antidepressants, antiseizure medications -Caution the patient about the long-term use of aspirin and aspirin-containing drugs because they can cause upper gastrointestinal (GI) bleeding and coagulation abnormalities in susceptible patients. -Drugs containing acetaminophen (Tylenol) can cause kidney damage with chronic use and liver damage when taking large doses or when combined with alcohol.

seizure

-Paroxysmal, uncontrolled electrical discharge of neurons in brain, interrupting normal function -May accompany other disorders or occur spontaneously without apparent cause -Those resulting from metabolic disturbances are not considered epilepsy if they cease when underlying condition is treated. Primary - Generalized (both hemispheres) -Tonic-Clonic -Absence -Myoclonic -Tonic - stiffing -Atonic (Akinetic) - loss of muscle tone -Clonic - jerking movements Focal (one hemisphere): -Simple, complex, evolve into secondary Nursing Interventions: -Promote safety measures -Wear helmet if risk for head injury. -General health habits (diet, exercise) -Assist to identify events or situations precipitating seizures and avoid if possible. -Instruct to avoid excessive alcohol, fatigue, and loss of sleep. -Help the patient to handle stress constructively. Metabolic Disturbances Associated with Seizures Include: -Acidosis -Electrolyte imbalances -Hypoglycemia -Hypoxemia -Alcohol or barbiturate withdrawal -Dehydration or water intoxication Extracranial Diseases Associated with Seizures: -Heart -Lung -Liver -Kidneys -Hypertension -Systemic lupus erythematosus -Diabetes mellitus -Septicemia Complications: ●Status epilepticus: -A state of constant seizure or condition when seizures recur in rapid succession without return to consciousness between seizures; prolonged seizures that last more than 5 minutes of repeated seizures over the course of 30 minutes -Most serious complication of epilepsy -Neurologic emergency -Can involve any type of seizure -Status epilepticus causes the brain to use more energy than is supplied. -Neurons become exhausted and cease to function. -Permanent brain damage can result. -Subclinical seizures are a form of status epilepticus in which the sedated patient seizes, but without external signs because of the sedating medication. -For example, a patient under sedation for ventilatory support in the ICU could experience a seizure without physical movements. -The health care providers caring for the patient may miss the seizure occurrence. -Tonic-clonic status epilepticus: most dangerous, can cause ventilatory insufficiency, hypoxemia, cardiac arrhythmias, hyperthermia, and systemic acidosis; can be fatal ●Severe injury and death from trauma during a seizure -Patients who lose consciousness are at greatest risk. -Persons with epilepsy have a mortality rate 2-3 times the rate of the general population. ●Effect on lifestyle is the most common complication of seizure disorder. -Social stigma still exists. -Discrimination/ limitations in employment and education -Driving sanctions ●Sudden unexplained death in epilepsy (SUDEP) -Higher in males, those on multiple antiseizure medications, and patients with long-standing epilepsy. -The direct cause of SUDEP is unknown, but it is thought to be related to respiratory dysfunction, cardiac dysrhythmias, or cerebral depression Risk Factors: -Metabolic disorders -Acute alcohol withdrawal or substance abuse -Electrolyte disturbances (such as hyperkalemia) -High fever -Stroke or head injury -Heart disease -Genetics (absence seizures) -Hypoglycemia -Dehydration -Water intoxication Health History Assessment: -Birth defects or injuries at birth -Anoxic episodes -CNS trauma or infections -Stroke -Metabolic disorders -Alcoholism -Exposure to metals or carbon monoxide -Hepatic or renal failure Nursing Assessment: -Bitten tongue, soft tissue damage, cyanosis -Abnormal respiratory rate -Apnea (ictal) -Absent or abnormal breath sounds -Airway occlusion -Hypertension, tachy/bradycardia -Bowel/urinary incontinence, excessive salivation -Weakness, paralysis, ataxia (postictal) -Abnormal CT, MRI, EEG Clinical Manifestations: -Prodromal phase: precedes seizure with signs or activity -Aural phase: sensory warning -Ictal phase: full seizure -Postictal phase: rest and recovery -Decerebration is abnormal movement with rigidity characterized by extension of the arms and legs, pronation of the arms, plantar flexion, and opisthotonos (body spasm in which the body is bowed forward) -Decerebration is usually associated with dysfunction in the brainstem area. Diagnostic Tests: -Drug testing -EEG -MRI, CT, PET Scan, X-Ray -CSF Planning: -Patient will be free from injury during seizure. -Patient will have optimal mental and physical functioning while taking antiseizure medications. -Patient will have satisfactory psychosocial functioning. Acute Nursing Interventions: -Observe, treat, and document seizure. -Maintain patent airway, support head, turn to side, loosen constrictive clothing, ease to floor. -Do not restrain patient or place any objects in their mouth. -May require positioning, suctioning, or oxygen after seizure. -Note all aspects of the seizure. What events preceded the seizure? When did the seizure occur? How long did each phase (aural [if any], ictal, postictal) last? What occurred during each phase? -Both subjective data (usually the only type of data in the aural phase) and objective data are important. Note the exact onset of the seizure (which body part was affected first and how); the course and nature of the seizure activity (loss of consciousness, tongue biting, automatisms, stiffening, jerking, total lack of muscle tone); the body parts involved and their sequence of involvement; and the presence of autonomic signs, such as dilated pupils, excessive salivation, altered breathing, cyanosis, flushing, diaphoresis, or incontinence. -Assessment of the postictal period should include a detailed description of the level of consciousness, vital signs, pupil size and position of the eyes, memory loss, muscle soreness, speech disorders (aphasia, dysarthria), weakness or paralysis, sleep period, and the duration of each sign or symptom. -A seizure can be a frightening experience for the patient and for others who may witness it. Assess the level of their understanding and provide information about how and why the event occurred. This is an excellent opportunity for you to dispel many common misconceptions about seizures. Seizure Precautions: -Oxygen -Suction equipment -Airway -IV access -Side rails up and padded Ambulatory and Home Care Nursing Interventions: -Prevention of recurring seizures is the major goal in treatment. -Instruct on importance of adherence to medication, not to adjust dose without physician; if a dose is missed, usually the dose should be made up if the omission is remembered within 24 hours. -Keep regular appointments. -Teach family members emergency management: it is not necessary to call an ambulance or send a person to the hospital after a single seizure unless the seizure is prolonged, another seizure immediately follows, or extensive injury has occurred.. -Emotional support and identification of coping mechanisms to adjust to personal limitations imposed by the disease -Medical alert bracelets -Referrals to agencies and organizations -For issues relating to job discrimination, refer patients to the state human rights commission or the state department of vocational rehabilitation. -Encourage the patient to learn more about epilepsy through self-education materials. Acute Seizure Medications: ●Seizure disorders are primarily treated with antiseizure drugs. ○The goal of therapy is preventing seizures with minimum toxic side effects from drugs. ○Medications control seizures in about 70% of patients. ●Drugs for seizure disorder must be taken regularly and continuously, often for a lifetime. ●Teach patients the importance of following the specific drug regimen and what to do if a dose is missed ●Medication depends on type of seizure ●Medication for tonic-clonic seizure activity may include: ○Lorazepam (Ativan) ○Diazepam (Valium) ○Diastat ○IV phenytoin (Dilantin) or fosphenytoin (Cerebyx) ○Carbamazepine (Tegretol) ○Phenobarbital (Luminal) ○Divalproex (Depakote) ○Primidone (Mysoline) ●Common side effect of phenytoin is gingival hyperplasia (excessive growth of gingival tissue) and hirsutism, especially in young adults. ●Common side effects involve the CNS and include diplopia, drowsiness, ataxia, and mental slowing. ●Neurologic assessment involves testing for toxicity: ○Nystagmus ○Hand and gait coordination ○Cognitive functioning ○General alertness ●Noncompliance is a concern. Collaborative Care: -Most seizures do not require emergency medical care because they are self-limiting and rarely cause bodily injury. -Immediate medical care if: ○Status epilepticus occurs. ○Significant bodily harm occurs. ○The event is a first-time seizure. -Biofeedback is aimed at teaching the patient to maintain a certain brain-wave frequency that is refractory to seizure activity. Further trials are needed to assess the effectiveness of biofeedback for seizure control. Gerontologic Considerations: -The incidence of new-onset seizure disorders is high among older adults. -Carefully consider the relationship between the action of antiseizure drugs and normal changes that occur with aging. -Phenytoin may be problematic for older adults with compromised liver function. -Phenobarbital, Tegretol, Mysoline negatively affect cognitive function. -Drug interactions with carbamazepine, phenytoin, phenobarbital -Newer antiseizure meds may be safer for older adults because they have fewer effects on cognitive function and less drug interactions: gabapentin, lamotrigine, oxcarbazepine, and levetiracetam Surgery: -To remove the epileptic focus or prevent the spread of epileptic activity in the brain -Requirements for surgery: diagnosis of epilepsy confirmed, adequate trial with drug therapy without satisfactory results, electroclinical syndrome defined -Benefits: cessation of seizures and reduction in frequency of seizures -Anterior temporal lobe resection is the most common surgical intervention -About 70% of patients are essentially seizure free after this procedure -Not all types of epilepsy benefit from surgery Vagal Nerve Stimulation: -Adjunct to medications when surgery is not feasible -Exact mechanism is not known -Thought to interrupt synchronization of epileptic brain-wave activity and stop excessive discharge of neurons -A surgically implanted electrode in the neck is programmed to deliver the electrical impulses to the vagus nerve. -The patient can activate it with a magnet when he or she senses a seizure is imminent. -Vagal nerve stimulation can cause adverse effects such as coughing, hoarseness, dyspnea, and tingling in the neck. -Battery replacement is required via surgery about every 5 years. Ketogenic Diet: -Has been effective in controlling seizures in some people -High-fat, low carbohydrate diet -Ketones pass into the brain and replace glucose as an energy source. -The long-term effects of the diet are not clear. -Patients on this diet who use anticoagulants need close monitoring for bleeding. Status Epilepticus Nursing Interventions: -Establish airway -ABGs -IV push lorazepam, diazepam -Rectal diazepam -Loading dose IV phenytoin Patient and Family Education: -Compliance with AEDs (antiepileptic drugs) -Social service resources to assist with medication costs -Evaluation of employment safety needed to decrease risks -Vocational rehabilitation may be subsidized

headache

-Primary: not caused by disease or another medical condition (types: tension-type, migraine, cluster) -Secondary: caused by another condition or disorder (for example, sinus infection, neck injury, or brain tumor) Nursing Assessment: Health history: -Seizures, cancer, stroke, trauma, asthma or allergies, mental illness, stress, menstruation, exercise, food, bright lights, noxious stimuli -Medications -Surgery and other treatments -Family history Objective Data: -Anxiety or apprehension -Diaphoresis, pallor, unilateral flushing with cheek edema, conjunctivitis Specific Details About the Headache: -Location, type of pain -Onset, frequency, duration, time of day -Relation to outside events Interprofessional Care: -If no systemic underlying disease is the cause, the type of headache guides therapy -Symptomatic and preventive therapies are used: drugs, medications, yoga, biofeedback, cognitive-behavioral therapy, and relaxation training -Biofeedback involves the use of physiologic monitoring equipment to give the patient information regarding muscle tension and peripheral blood flow (e.g., skin temperature of the fingers). The patient is trained to relax the muscles and raise the finger temperature and is given reinforcement (operant conditioning) in accomplishing these changes. -Acupuncture, acupressure, and hypnosis are also therapies that have worked well in some patients with headaches. Planning/Goals: -Have decreased or no pain -Demonstrate understanding of triggering events and treatment strategies -Use positive coping strategies -Experience increased quality of life and decreased disability Nursing Interventions: -Teach patient about preventive treatment -Dietary counseling for food triggers: avoid chocolate, cheese, oranges, tomatoes, onions, monosodium glutamate, aspartame, alcohol (particularly red wine), excessive caffeine, and fermented or marinated foods -Avoid smoking and other environmental triggers such as strong perfumes, volatile solvents, and gasoline fumes. -Cluster headaches may occur at high altitudes with low oxygen levels during air travel; ergotamine, taken before the plane takes off, may decrease the likelihood of these attacks -An inability to cope with daily stresses can cause headaches: an effective therapy may involve helping the patient examine the daily routine, recognize stressful situations, and develop more appropriate coping strategies. -Daily exercise, relaxation periods, and socializing help reduce recurrence and should be encouraged -Suggest alternative pain management such as relaxation, meditation, yoga, and self-hypnosis -Effective therapy may be to help patients: examine their lifestyle, recognize stressful situations, learn to cope more appropriately -Encourage a quiet, dim environment -Massage and heat packs can help with tension-type -Patient should make a written note of medications to prevent accidental overdose Expected Outcomes: -Reports satisfaction with pain management -Uses drug and nondrug measures appropriately to manage pain

osteomyelitis

-Severe infections of the bone, bone marrow, and surrounding soft tissue Risk Factors: -Diabetes -Orthopedic prosthetic implants -Vascular insufficiency Clinical Manifestations: -Bone pain -Swelling -Tenderness -Warmth -Restricted movement -Systemic: fever, night sweats, chills, restlessness, nausea, malaise Diagnostic Studies: -Soft tissue biopsy -Blood, wound, bone cultures -WBC, ESR, CRP -X-ray: it will not initially appear until 2-4 weeks -CT can show the extent of infection -MRI can show bone marrow edema (early sign) -Radionucleotide scans will show abnormalities earlier than an x-ray Interprofessional Care: -Aggressive & long term IV antibiotic therapy when there is no bone ischemia: starts in the hospital and continues at home once the client is discharged; oral, IV, bead chains -Related soft tissue damage and abscesses are debrided and drained -Hyperbaric oxygen therapy -Amputation Nursing Interventions: -Health promotion -Limb stabilization -Pain: •How is the limb handled •Muscle spasms •Administer NSAIDS, opioids, muscle relaxants •Non-pharmacological interventions -Dressings -Initially on bedrest -Body alignment, contractures -Teach client about reactions to high dose antibiotic therapy: •Hearing deficit •Impaired renal function •Neurotoxicity (weakness, numbness, cognitive changes) •Vision changes •Headache •Behavioral problems

delirium

-State of temporary but acute mental confusion -Common problem -Life-threatening syndrome -Often preventable and/or reversible -Affects as many as 50% of people older than 65 years who are hospitalized, and as many as 80% of patients in an ICU. Causes: -Impairment of cerebral oxidative metabolism -Multiple neurotransmitter abnormalities may also be involved -Cholinergic deficiency -Excess release of dopamine ↑ and ↓ serotonergic activity Etiology and Pathophysiology: -Dementia is leading risk factor -Delirium is a risk factor for subsequent development of dementia -May cause permanent neuronal damage -Linked to onset: stress, surgery, sleep deprivation, pain, and depression Predisposing Factors: -Cognitive status: dementia, cognitive impairment, depression, history of delirium -Environmental: admission to ICU, use of physical restraints, pain (especially untreated), emotional stress, prolonged sleep deprivation -Functional status: functional dependence, immobility history of falls -Sensory: sensory deprivation, sensory overload, visual or hearing impairment -Decreased oral intake: dehydration, malnutrition -Drugs: sedative-hypnotics, opioids anticholinergic drugs, aminoglycoside s, treatment with multiple drugs, alcohol or drug abuse or withdrawal -Coexisting medical conditions: severe acute or terminal illness, electrolyte imbalances, chronic kidney or liver disease, history of stroke, neurologic disease, infection/sepsis/ fever, fracture or trauma -Surgery: orthopedic surgery, cardiac surgery, prolonged cardiopulmonary bypass, noncardiac surgery Mnemonic for Causes: -Dementia, dehydration -Electrolyte imbalances, emotional stress -Lung, liver, heart, kidney, brain -Infection, ICU -Rx Drugs -Injury, immobility -Untreated pain, unfamiliar environment -Metabolic disorders Clinical Manifestations: -Can present with a variety of manifestations, ranging from hypoactivity and lethargy to hyperactivity, including agitation and hallucinations. -Usually develops over a 2- to 3-day period -Can develop within hours -Patients can also have mixed delirium, manifesting both hypoactive and hyperactive symptoms. -Can last from 1 to 7 days -Some manifestations may persist for months or years -Some patients do not completely recover -Manifestations are sometimes confused with dementia -Key distinctions of delirium rather than dementia: sudden cognitive impairment, disorientation, clouded sensorium Early Manifestations: -Inability to concentrate -Disorganized thinking -Irritability -Insomnia -Loss of appetite -Restlessness -Confusion Later Manifestations: -Agitation -Misperception -Misinterpretatio n -Hallucinations Diagnostic Studies: -Diagnosis complicated by inability to communicate -Medical history -Psychologic history -Physical examination -Careful attention to medications -Cognitive measures: Confusion Assessment Method (CAM) -Laboratory tests to explore the cause: serum electrolytes, blood urea nitrogen level, creatinine level, complete blood count (CBC), drug and alcohol levels, electrocardiogram (ECG), urinalysis, liver and thyroid function tests, oxygen saturation level, lumbar puncture (used if a fever or nuchal rigidity is present, or if meningitis or encephalitis is suspected) Nursing/ Interprofessional Management: -Treatment is important since many cases are potentially reversible -Your role in caring for a patient with delirium: prevention, early recognition, and treatment -Prevention of delirium involves recognition of high-risk patients. -Patient groups at risk include those with neurologic disorders (e.g., dementia, stroke, CNS infection, Parkinson's disease), sensory impairment, and older age. -Other risk factors include surgery, hospitalization in an ICU, and untreated pain. -Focus on eliminating precipitating factors -Protect patient from harm -Encourage family members to stay at bedside -Care of the patient with delirium focuses on eliminating precipitating factors. -If it is drug induced, medications are discontinued. -Keep in mind that delirium can also accompany drug and alcohol withdrawal. -Depending on patient history, drug screening may be performed. -Fluid and electrolyte imbalances and nutritional deficiencies (e.g., thiamine) are corrected if appropriate. -If the problem is related to environmental conditions (e.g., an overstimulating or understimulating environment), changes should be made. -If delirium is secondary to chronic illness such as chronic kidney disease or heart failure, treatment focuses on these conditions. -If delirium is secondary to infection, antibiotic therapy is started -Reorientation and behavioral interventions—used in all patients with delirium -Create a calm and safe environment -Provide reassurance -Pay attention to environmental stimuli: clocks, calendars, noise, and light levels -Personal contact through touch and verbal communication can be an important reorienting strategy. -If the patient uses eyeglasses or a hearing aid, these should be made readily available because sensory deprivation can precipitate delirium. -Avoid the use of restraints. -A therapeutic environment may include encouraging family members to stay at the bedside, providing familiar objects and family photos, transferring the patient to a private room or one closer to the nurses' station, and planning for consistent nursing staff if possible. -Patient experiencing delirium is also at risk for immobility and skin breakdown -Nurse should also focus on supporting the family and caregivers -The interprofessional care team may need to address issues related to polypharmacy, pain, nutritional status, and potential for incontinence. -Give attention to increasing physical activity or providing range-of-motion exercises, when appropriate, and maintaining skin integrity. Drug Therapy: -Reserved for those patients with severe agitation -Interferes with needed medical therapy -Puts patient at increased risk for falls and injury -Used when nonpharmacologic interventions have failed -Used cautiously because many of the drugs used to manage agitation have psychoactive properties. -Dexmedetomidi ne (Precedex) for sedation -Neuroleptics: haloperidol,(Haldol), risperidone, (Risperdal) olanzapine (Zyprexa), quetiapine (Seroquel), -Short-acting benzodiazepines -Dexmedetomidi ne (Precedex), an α-adrenergic receptor agonist, has been used in ICU settings for sedation. -Haloperidol can be administered IV, IM, or orally and will produce sedation. -In addition to sedation, other side effects with antipsychotics include hypotension; extrapyramidal side effects, including tardive dyskinesia (involuntary muscle movements of the face, trunk, and arms) and athetosis (involuntary writhing movements of the limbs); muscle tone changes; and anticholinergic effects. -Carefully monitor older patients receiving antipsychotic agents. -Short-acting benzodiazepines (e.g., lorazepam [Ativan]) can be used to treat delirium associated with sedative and alcohol withdrawal or in conjunction with antipsychotics to reduce extrapyramidal side effects. -However, these drugs may worsen delirium caused by other factors and must be used cautiously.

total joint arthroplasty

-Surgical removal of a diseased or fractured joint -Partial (hemi) or total replacement (hip, knee, etc.) -Joint is replaced with a metal/plastic joint Assessment: -Risk factors (including meds) -Musculoskeletal -Mobility & function -Pain (+/- weight bearing)

brain stent used to treat blockages

-Surgical treatment for strokes -Used to treat blockage in cerebral blood flow -A balloon catheter is used to implant the stent into an artery of the brain. -The balloon catheter is moved to the blocked area of the artery and then inflated. -The stent expands due to inflation of the balloon. -The balloon is deflated and withdrawn, leaving the stent permanently in place holding the artery open and improving the flow of blood. Postoperative Care is Important: -Neurovascular assessment -BP management -Assessment for complications: stent occlusion, retroperitoneal hemorrhage -Minimize complications at insertion site

traction

-The application of a pulling force to a part of the body to provide: •Reduction •Alignment •Rest •Decrease muscle spasm •Prevent or correct deformity and tissue damage -Although not used as often today, the two most common types are skin and skeletal -The primary purpose of skin traction is to: •Decrease painful muscle spasms that accompany hip fractures •Stabilize the fracture so it doesn't move •Involves the use of a Velcro boot (Buck's traction) secured around the affected leg. •Weights are used as a pulling force, which is ordered by the provider •Weights should be freely hanging at all times and are usually not removed without an order •SKIN assessment is CRITIAL -The primary purpose of skeletal traction is to: •Decrease painful muscle spasms that accompany hip fractures •Stabilize the fracture so it doesn't move •Skeletal pins or wires can be inserted through the skin and into bone (e.g., halo traction) for the purpose of skeletal traction or external fixation. •Provide pin care for patients with skeletal traction or external fixation •Assess for manifestations of infection at the pin sites.

osteoarthritis

-The most common arthritis and a major cause of disability among adults in the United States and the world -Non-inflammatory -Also referred to as degenerative joint disease (DJD) -More common in older patients -Often accompanies other diseases. such as psoriasis, Crohn's disease, and hemophilia -The presence of inflammation in patients with osteoarthritis indicates a secondary synovitis Causes: -Aging -Genetic factors -Joint injury -Obesity -Heavy manual occupations -Trauma Clinical Manifestations: -Complaints of chronic joint pain and stiffness -Joint tenderness on palpation -Crepitus may be present with ROM -Enlarged joints related to bony hypertrophy -Joints feel hard on palpation -If inflammation is present, it indicates secondary synovitis -Heberden's nodes: bony nodules at the distal interphalangeal joints -Bouchard's nodes: bony nodules at the proximal interphalangeal joints Diagnostics: -No one lab or diagnostic test that specifically identifies the diagnosis -Routine lab work is generally normal -ESR may be elevated -C-Reactive Protein may be elevated -Routine x-rays to observe for joint changes -MRI -CT scan Drug Therapy: -Purpose is to reduce pain and secondary joint inflammation -No drug therapy can influence the course -Acetaminophen -Topical lidocaine -NSAIDs (PO and topical) -Flexeril (muscle spasms) -Ultram Alternate Therapies: -Rest balanced with exercise -Joint positioning: position joints in their functional position, wear supportive shoes -Heat or cold applications -Weight control -Range of motion -Light exercised -Physical therapy: muscle strengthening exercises -If other measures ineffective, surgery may be performed to reduce pain Nursing Interventions: -Manage chronic pain -Increase mobility to allow patients to function as independently as possible -Teach patients to eat a well-balanced diet, follow a weight reduction program if obese, avoid trauma, and limit strenuous weight-bearing activities -Teach arthritic patients about the benefits of exercise, joint protection techniques, and energy conservation guidelines. -Instruct patients with arthritic pain to use multiple modalities for pain relief, including ice/heat, rest, positioning, complementary and alternative therapies, and medications as prescribed. -Assess for therapeutic effects of drugs used for arthritis. -Teach patients to monitor and report side and adverse effects. -Implement interventions to prevent venous thromboembolic complications, for example, anticoagulants, exercises, and sequential compression devices. -Observe the patient for bleeding when he or she is taking anticoagulants. -Implement interventions for patients having total joint arthroplasty (TJA) to prevent venous thromboembolic complications (e.g., anticoagulants, exercises, sequential compression devices); observe the patient for bleeding when he or she is taking anticoagulants, and have all necessary dental procedures done prior to surgery to avoid infection. -Encourage patients with arthritis and connective tissue diseases to discuss their chronic illness and pain and identify coping strategies that have previously been successful. -Provide information about community resources for patients, especially professional organizations such as the Arthritis Foundation.

Alzheimer's disease

-The most common form of dementia, accounting for 60% to 80% of all cases of dementia -Chronic, progressive, neurodegenerative brain disease -Only cause of death among the top 10 that cannot be prevented, cured, or even slowed -Burden of care is staggering -Known as the "long good-bye" or "death in slow motion" -Incidence is higher in African Americans and Hispanics -Has been associated with lower socioeconomic status and education level and poor access to health care -Women are more likely than men to develop it, primarily because they live longer Pathophysiology: -Abnormal amounts of β-amyloid are cleaved from the amyloid precursor protein (APP) and released into the circulation. The β-amyloid fragments come together in clumps to form plaques that attach to the neuron. Microglia react to the plaque, and an inflammatory response results. -Tau proteins provide structural support for the neuron microtubules. Chemical changes in the neuron produce structural changes in tau proteins. This results in twisting and tangling (neurofibrillary tangles). -Plaques and neurofibrillary tangles are not unique to patients with this disorder. They are also found in the brains of individuals without evidence of cognitive impairment. However, they are more abundant in the brains of individuals with this disorder -Gradual loss of connections between neurons and neuron death -Results in structural damage -Affected parts of brain shrink -Brain atrophy -Significant in final state -Pathologic changes precede clinical manifestations by 5 to 20 years Early Warning Signs: -Memory loss that affects job skills -Difficulty performing familiar tasks -Problems with language -Disorientation to time and place -Poor or ↓ judgment -Problems with abstract thinking -Misplacing things -Changes in mood or behavior -Changes in personality -Loss of initiative -Trouble with words and numbers Diagnostic Studies: -Comprehensive patient evaluation: complete health history, physical examination, neurologic assessment, mental status assessment -Laboratory tests -Brain imaging tests: CT, MRI, PET help detect early changes in the disease process, differentiate from other forms of dementia, and enable monitoring of treatment response -No definitive diagnostic test exists -Diagnosed by exclusion -Made once all other possible conditions causing cognitive impairment have been ruled out -Neuropsycholo gic testing can help document degree of cognitive impairment: Mini-Cog, Mini-Mental State Examination (MMSE); also used to determine a baseline from which to evaluate change over time -The clock drawing test can be used as part of the Mini-Cog or by itself to assess cognitive function. Nursing Assessment: Subjective Data: -Past health history -Medications -Health perception-health management -Nutritional-metabolic -Elimination (incontinence) -Activity-exercise -Sleep-rest pattern -Cognitive-perceptual -Useful questions for the patient and informant are, "When did you first notice the memory loss?" and "How has the memory loss progressed since then?" Objective Data: -Disheveled appearance -Neurologic: early, middle, late changes Interprofessional Care: -No cure -No treatment exists to stop the deterioration of brain cells -Interprofession al care is aimed at: delaying onset of symptoms, controlling undesirable behavioral manifestations, providing support for family caregiver Drug Therapy: -Drugs available today help many people but not for very long and not very well -Some modest ↓ in rate of decline of cognitive function -No effect on overall disease progression -Memantine (Namenda) protects nerve cells against excess amounts of glutamate; glutamate is released in large amounts by cells damaged by AD -Treating associated depression may improve cognitive ability and may help with sleep problems; SSRIs are often used -Antipsychotic drugs manage behavioral problems and ↑ the risk of death in older patients -Selective serotonin reuptake inhibitors include fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), and citalopram (Celexa). -The antidepressant trazodone (Desyrel) may help with problems related to sleep. However, this agent may result in hypotension. -Although antipsychotic drugs are approved for treating psychotic conditions (e.g., schizophrenia), they have been used for the management of behavioral problems (e.g., agitation, aggressive behavior) that occurs in patients -The Food and Drug Administration (FDA) has warned that antipsychotics are not indicated for the treatment of dementia-related psychosis. However, the warning does not mean that the drugs cannot be used for these patients with dementia. Planning/Goals: -Maintain functional ability as long as possible -Be maintained in a safe environment with a minimum of injuries -Have personal care needs met -Have dignity maintained -Goals for caregivers: reduce caregiver stress; maintain personal, emotional, and physical health; cope with long-term effects of caregiving Health Promotion: 1.Avoid harmful substances: Excessive drinking and drug abuse can damage brain cells. Stop smoking as it increases the risk of cognitive decline. 2. Challenge your mind: Read frequently, do crossword puzzles. Keep mentally active. Learn new skills. Go back to school. This strengthens the brain connections and promotes new ones. 3. Exercise regularly: Even low to moderate level activity such as walking or gardening three to five times per week can make you feel better. Daily physical activity, even in older adults, can decrease the risk for cognitive decline. 4. Stay socially active: Pursue social activities that have meaning to you. Family, friends, church, and a sense of community may all contribute to better brain health. 5. Avoid trauma to the brain: Because traumatic brain injury may be a risk factor for developing AD, promote safety in physical activities and driving. Use the car seat belt. Wear a helmet when playing contact sports or riding a bike. Fall proof your home. 6. Take care of mental health: Recognize and treat depression early. Depression may cause or worsen memory loss and other cognitive impairment. 7. Treat diabetes: Better blood glucose control can help to prevent the cognitive decline associated with diabetes. 8. Take care of your heart: Risk factors for cardiovascular disease and stroke (hypertension, obesity) negatively impact your cognitive health. Heart health is linked to brain health. 9. Get enough sleep: Not getting enough sleep may result in problems with memory and thinking. 10. Get the right fuel: A healthy and balanced diet low in fats and high in vegetables and fruits help to reduce the risk of cognitive decline. Acute Care: -Diagnosis is very traumatic -Patient often responds with: depression, denial, anxiety and fear, withdrawal, and feelings of loss -In the early stages, patients are often aware that their memory is faulty and do things to cover up or mask the problem. -Patients subject to hospitalization for other problems -Inability to communicate symptoms places responsibility on caregiver and health care professionals -Hospitalization can precipitate worsening of dementia and development of delirium -Patients with AD hospitalized in the acute care setting will need to be observed more closely because of concerns for safety, frequently oriented to place and time, and given reassurance. -Anxiety or disruptive behavior may be reduced with using consistent nursing staff. Behavioral Problems: -Occur in most patients (90%) -These problems include: repetitiveness, delusions, hallucinations, agitation, aggression -Problems: altered sleep patterns, wandering, hoarding, resisting care -Can be unpredictable and challenging -Often lead to placement of patients in institutional care settings -Are a patient's way of responding to a precipitating factor: pain, frustration, temperature extremes, anxiety, excessive noise Behavioral Problems Nursing Interventions: -Assess patient's physical status and environment; check for changes in vital signs, urinary and bowel patterns, and pain that could account for behavioral problems. -Move patient or remove stimulus -Reassure patient about safety -Rely on mood and behavior rather than verbal communication -Don't ask patient "why"; the person with AD cannot think logically -If the patient cannot verbalize distress, validate his or her mood. -Rephrase the patient's statement to validate its meaning. -Closely observe the patient's emotional state. -Nursing strategies to address difficult behaviors: redirection, distraction, reassurance -Do not threaten to restrain patient or call HCP -Exhaust options before using drugs -Use reality orientation to orient to time, place, and person. -Ways to distract the agitated patient may include providing snacks, taking a car ride, sitting on a porch swing or rocker, listening to favorite music, watching videotapes, looking at family photographs, or walking. -Use of repetitive activities, songs, poems, music, massage, aromas, or a favorite object can be soothing to patients. -A calming family member can be asked to stay with the patient until the patient becomes calmer. -Monitor the patient frequently, and document all interventions. -The use of positive nurse actions can reduce the use of chemical (drug therapy) restraints. -Disruptive behaviors have been treated with antipsychotic drugs. Before these drugs are used, all other measures of treating behavioral issues should be exhausted. Sundowning: -Specific type of agitation -Patient becomes more confused and agitated in late afternoon or evening -May be due to disruption of circadian rhythms -Behaviors related to sundowning include agitation, aggressiveness, wandering, resistance to redirection, and increased verbal activity such as yelling. -Possible causes include fatigue, unfamiliar environment and noise (especially in an acute care setting), medications, reduced lighting, and sleep fragmentation. Sundowning Nursing Interventions: -Create a quiet, calm environment -Maximize exposure to daylight: open blinds and turn on lights during the day -Evaluate medications to determine if any could cause sleep disturbances -Limit naps and caffeine -Consult health care provider on drug therapy -When a patient has sundowning, remain calm and avoid confrontation. -Assess the situation for possible causes of the agitation. -Management of sundowning can be challenging for you, the patient, and the family. Safety Risks: -Injury from falls -Ingesting dangerous substances -Wandering -Injury to others and self with sharps -Burns -Inability to respond to crisis Wandering: -A major concern -Wandering may be related to loss of memory or to side effects of drugs, or it may be an expression of a physical or emotional need, restlessness, curiosity, or stimuli that trigger memories of earlier routines. -Observe for precipitating factors or events -Patient can be registered with Medical Alert + Safe Return -The Safe Return program includes identification products (e.g., bracelet, necklace, wallet cards), a national photo/information database, a 24-hour toll-free emergency crisis line, local chapter support, and wandering behavior education and training for caregivers and families. -Tracking devices such as a global positioning system (GPS) can also be used to detect and find people who wander. These devices can be placed in shoes, sewn into pockets, worn as a bracelet or pendant, or clipped to a belt. Pain Management: -Because of difficulties with oral and written language associated with AD, patients may have difficulty expressing physical complaints, including pain. -Pain can result in alterations in the patient's behavior, such as increased vocalization, agitation, withdrawal, and changes in function. -Dental caries and tooth abscess can add to patient discomfort or pain and subsequently may increase agitation. -In late stages, patient will be unable to perform oral self-care -Dental problems are likely to occur -Patient may pocket food, adding to potential tooth decay -Inspect mouth regularly and provide mouth care -Because of feeding and swallowing problems, the patient with AD is at risk for aspiration pneumonia. -Reduced fluid intake, prostate enlargement in men, poor hygiene, and urinary drainage devices (e.g., catheter) can predispose to bladder infection. -Any manifestations of infection, such as a change in behavior, fever, cough (pneumonia), or pain on urination (bladder), need prompt evaluation and treatment. -Urinary and fecal incontinence during middle to late stages -Habit or behavioral retraining may ↓ episodes -Constipation may relate to immobility, dietary intake, ↓ fluids -Caregiver support: AD disrupts all aspects of personal and family life; very stressful; caregivers also exhibit adverse consequences; can result in family conflict and strain Relationships Change: -As the disease progresses, the relationship of the caregiver to the patient changes. -Family roles may be altered or reversed (e.g., son caring for father). -Decisions must be made, including when to tell the patient about the diagnosis, when to have the patient stop driving or doing activities that might be dangerous, when to ask for assistance, and when to place the patient in adult day care or a long-term care facility. -With early-onset, the patient is affected during his or her most productive years in terms of career and family. -The consequences can be devastating for the patient and family. -Sexual relations for couples are also seriously affected -As the disease progresses, sexual interest may decline for both the patient and partner. -A number of reasons account for this, including fatigue, memory impairment, and episodes of incontinence. -The patient may also become sexually driven as the disease progresses and the patient becomes more uninhibited. Caregiver Support: -Caregiving increases risk for development of dementia -Chronic and severe stress can affect the hippocampus -Hippocampus is a region of the brain responsible for memory -Assess caregiver expectations -Work with the caregiver to assess stressors and to identify coping strategies to reduce the burden of caregiving. -For example, ask which behaviors are most disruptive to family life at a given time, while remembering that this is likely to change as the disease progresses. -Determining what the caregiver views as most disruptive or distressful can help to establish priorities for care. -Safety of the patient is a high priority. It is also important to assess what the caregiver's expectations are regarding the patient's behavior. Are the expectations reasonable given the progression of the disease? Expected Outcomes: -Functions at highest level of cognitive ability -Experiences no injury -Remains in restricted area during ambulation and activity -Performs basic personal care activities of daily living including bathing, dressing, feeding, and toileting by self or with assistance as needed

hip fractures/total hip arthroplasty

-The primary nursing concern is assessment and prevention of neurovascular dysfunction or compromise. -Marked neurovascular compromise will significantly decrease arterial perfusion, and increase the risk of complications. -Perform a thorough neurovascular assessment, evaluating circulation, movement, and sensation (sensory perception). -Assess skin color and temperature, sensation, mobility, pain, and pulses distal to the fracture site. -Leg length, external rotation, adduction Additional risk factors specific to hip fractures: -Female -Over 80 -Hx of osteoporosis -Low estrogen, menopausal women -Comorbid condition that has side effects of imbalances & falling Diagnostics: -Standard x-rays confirm a diagnosis of fracture, revealing the bone disruption, malalignment, or deformity. -Computed tomography (CT) scanning is useful for fractures of complex structures, such as the hip and pelvis, and in identifying compression fractures of the spine. -Magnetic resonance imaging (MRI) is useful in determining the amount of soft-tissue damage that may have occurred with the fracture and in visualizing avascular necrosis. -ECG - often these clients will have cardiac issues, so we need to know if there have been any changes since their last ECG indicating a heart attack or ischemia. Lab Tests: -CBC - for baseline RBCs, Hgb, WBCs for blood levels & infection -BMP - determine if there are any electrolyte issues - this is connected to dehydration & poor nutrition, also for clients with compromised kidney function -U/A, C&S - to determine if there is a bladder infection -BS for diabetics -Liver enzymes for clients with compromised liver function Post Op Nursing Care: -Cough & deep breathe every 2 hours -Turn and reposition client every 2 hours -Thromboembolic stockings, SCDs, low molecular weight heparin to decrease VTE & venous stasis -Maintain leg abduction -Frequent neurovascular checks of affected and unaffected leg -Pain control -Client should be up and walking as soon as possible. Check the orders first! -Assess under the client for drainage and blood. -Abduction pillow -Floating heels -Assess for infection -Assist with mobility for orthostatic hypotension -Get patient out of bed when appropriate -Pain management -Reorient patient as needed Complications: -VTE -Fat embolism -Neurovascular complications - caused by bleeding, swelling -Atelectasis -Pneumonia -Pressure ulcers -Urinary retention -Infection -Nonunion Symptoms of Dislocation: -Sudden onset of pain -Inability to move leg -Shortening & external rotation of the leg Discharge Preparation/ Education: -Hip precautions -Pain management -Incision care -Other points: •When to call 911 •Follow-up •Exercises DVT Prevention

normal pressure hydrocephalus dementia

-Uncommon -Caused by obstruction of CSF flow -Meningitis, encephalitis, head injury -Manifestations: dementia, urinary incontinence and difficulty walking -Treatable by surgery in which a shunt is inserted to divert the fluid away from the brain (when diagnosed early)

neurovascular assessment

1)Pain 2) Parenthesis 3) Pallor 4) Paralysis 5) Pulselessness 6) Poikilothermia

FAST

Acronym to help recognize stroke symptoms: -Face: if you notice a droop or uneven smile on a person's face, this is a warning sign -Arms: arm numbness or weakness can be a warning sign. You can ask the person to raise their arms if you are unsure. It's a warning sign if the arm drops down or isn't steady. -Speech: Ask the person to repeat something. Slurred speech can indicate that the person is having a stroke -Time: act fast if someone is experiencing stroke symptoms