NUR 2033 Exam 4

DSM-5 Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder

A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2): 1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities (Note: The symp- toms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.): a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks and misses details, work is inaccurate). b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading). c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction). d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily side- tracked). e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines). f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers). g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts). i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments). 2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities (Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.): a. Often fidgets with or taps hands and feet or squirms in seat. b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place). c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.) d. Often unable to play or engage in leisure activities quietly. e. Is often "on the go," acting as if "driven by a motor" (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others being restless or difficult to keep up with). f. Often talks excessively. g. Often blurts out an answer before a question has been completed (e.g., completes other people's sentences; cannot wait for turn in conversation). h. Often has difficulty waiting his or her turn (e.g., while waiting in line). i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people's things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing). B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years. C. Several inattentive or hyperactive/impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities). D. There is clear evidence that symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal

Hearing Impairment Patho and Etiology

Alterations in hearing may be due to one or more factors. For example, lesions in the outer ear, middle ear, inner ear, or central auditory pathways can result in hearing loss. The process of aging also can affect the structures of the ear and hearing. Etiology Hearing loss is classified as conductive, sensorineural, or mixed, depending on what portion of the auditory system is affected. Profound deafness is often a congenital condition. Conductive Hearing Loss: Anything that disrupts the transmission of sound from the external auditory meatus to the inner ear results in a conductive hearing loss. The most common cause of conductive hearing loss is obstruction of the external ear canal. Impacted cerumen, edema of the canal lining, stenosis, and neoplasms all may lead to canal obstruction. Other causes of conductive loss include a perforated tympanic membrane, disruption or fixation of the ossicles of the middle ear, fluid, scarring, and tumors of the middle ear. Conductive loss also occurs if the tympanic membrane does not fully vibrate, as in otitis media. In these cases, loss may be restored after the infection clears. Chronic and untreated ear infections may lead to ear structural changes and permanent hearing impairment. The loss of acuity may be gradual or rapid and results in diminished hearing in all ranges. Sensorineural Hearing Loss: Disorders that affect the inner ear, the auditory nerve, or the auditory pathways of the brain may lead to a sensorineural hearing loss. In this type of hearing loss, sound waves are effectively transmitted to the inner ear. In the inner ear, however, lost or damaged receptor cells, changes in the cochlear apparatus, or auditory nerve abnormalities decrease or distort the ability to receive and interpret stimuli. Conditions leading to sensorineural hearing loss may be congenital, genetic, or acquired. In sensorineural hearing loss, high-frequency sounds are most affected. A significant cause of sensorineural hearing deficit is damage to the hair cells of the organ of Corti. In the United States, noise exposure is the major cause. Damage may result from either loud impulse noise (e.g., an explosion) or loud continuous noise (e.g., machinery). Exposure to a high level of noise (e.g., standing close to the stage or speakers at a rock concert) on an intermittent or continuing basis damages the hair and supporting cells of the organ of Corti. Other sources of potential damage to hearing include certain types of work (first responders, construction workers) and play (fireworks, concerts, firearms, and loud toys). Ototoxic drugs also damage the hair cells of the organ of Corti; when combined with high noise levels, the damage is greater and resultant hearing loss more profound. Other potential causes of sensory hearing loss include prenatal exposure to rubella, viral infections, meningitis, trauma, Ménière disease, and aging. Tumors such as acoustic neuromas (vestibular schwannomas), vascular disorders, demyelinating or degenerative diseases, infections (bacterial meningitis in particular), or trauma may affect the central auditory pathways and produce a neural hearing loss. Presbycusis: With aging, the hair cells of the cochlea degenerate, producing a progressive sensorineural hearing loss. In presbycusis, hearing acuity begins to decrease in early adulthood and progresses as long as the individual lives. Higher-pitched tones and conversational speech are lost initially.

Macular Degeneration Diagnostic Tests

AMD is diagnosed through vision and retinal examination. Diagnostic tests for AMD usually involve pupillary dilation, which can be an unsettling experience the first time the examination is performed. The nurse can instruct the client on how the exam is performed, what to expect, and that the dilation is temporary. The nurse should encourage the client to wear dark sunglasses until the pupils have returned to normal size (the client will experience photophobia with pupil dilation). The Amsler grid may be used to identify distortion of central vision caused by AMD. If treatment for wet AMD is planned, a fluorescein angiogram may be done. Pictures are taken as the dye passes through the blood vessels of the retina, allowing detection of leaks. Optical coherence tomography (OCT) is relatively new. It is noninvasive and involves taking cross-sectional images of the retina to measure its thickness. Areas with thinning are noted in clients with advanced AMD.

Cataracts Risk Factors

Age is the greatest single risk factor for cataracts. Genetics may contribute to the risk, although the link is unclear. Environmental and lifestyle factors play a role. Long-term exposure to sunlight (UVB rays) increases the risk for cataracts; cigarette smoking and heavy alcohol consumption are associated with earlier cataract development. Eye trauma, including injury to the lens capsule by a foreign body, blunt trauma, or exposure to heat or radiation, can precipitate cataract formation. Diabetes mellitus is associated with earlier development of cataracts, especially when the blood glucose level is not carefully controlled at or near normal levels. Certain drugs, such as systemic or inhaled corticosteroids, lovastatin (Mevacor), phenytoin (Dilantin), chlorpromazine (Thorazine), and busulfan (Myleran) also prompt the formation of cataracts.

Cataracts Nursing Process

Because aging is the single greatest risk factor for the development of cataracts, older adults are especially vulnerable to this impairment. However, as previously discussed, other factors may increase the risk for cataract development. From the standpoint of promoting wellness, all clients may benefit from client teaching regarding risk factors and preventive measures. For the client who has developed cataracts, the nursing process is geared toward both treatment and prevention of injury. Assessment Health history. Effect of vision changes on lifestyle and activities (e.g., ability to read, watch television, participate in work and recreational activities); history of smoking, diabetes, use of prescription drugs associated with increased risk of cataracts. Physical examination. General health; visual acuity (using corrective lenses and Snellen chart) in each eye; presence of red reflex, cloudy gray or white pupil. Diagnosis The client with cataracts has few physical care nursing needs. Client advocacy, psychological and emotional support, and teaching/learning needs are typically of high priority for these clients. Nursing diagnoses for the client with cataracts may include the following: -Risk for Injury related to visual impairment -Decisional Conflict: Cataract removal -Risk for Ineffective Health Maintenance. Planning Appropriate outcomes for the client diagnosed with cataracts include the following: -The client will remain free from injury. -The client will be able to articulate an understanding of the reasons for and risks involved with surgery. -The client will participate in self-care activities to protect eyes from further damage and to maximize safety. -The client will follow self-care instructions following surgery to ensure healing and to maximize benefits of surgery. Implementation With the initial diagnosis, teaching focuses on the disorder, indications for surgery, and vision restoration following cataract removal. Teaching adaptive strategies to deal with effects of the cataract on vision and depth perception also are useful. Prevent Injury Prior to surgery, the client can use a number of self-care activities to minimize further damage and to maximize safety. The nurse should teach the client to: -Wear sunglasses with UVA/UVB protection when outdoors. -Use reading or prescription glasses or contact lenses as necessary. -Maximize lighting for reading, cooking, and other indoor activities. -Limit or discontinue night time driving. After surgery, the client may experience mild to moderate discomfort and some fluid discharge. The nurse should explain that these symptoms normally subside in 1 or 2 days but that the client should call the office if the symptoms persist or become intolerable. Instruct the client to continue to wear eye protection as ordered and to avoid rubbing the eye. In most cases, healing will be complete in 7-8 weeks. Facilitate Informed Decision Making -Explain the nonemergent nature of the condition and help the client determine the extent to which the cataract is affecting daily life. This helps the client decide when to proceed with surgery. Providing information about cataracts and their surgical removal also assists with decision making. -Attend to verbalized concerns about surgery and its outcome. Address questions factually and completely. Fear of blindness is second only to fear of cancer for many clients. Careful listening and teaching and a caring, understanding attitude can help the client deal with this fear prior to surgery. Teach Principles of Self-Care -Assess for factors that may interfere with the client's ability to provide self-care postoperatively. A chronic condition that may affect the ability to administer eye drops, such as arthritis, may indicate the need to include a family member in teaching. -Assess for other care needs that may be impacted by vision changes in the early postoperative period. Other care needs, such as insulin injections, may suggest the need for home health or nursing care postoperatively. When surgery is scheduled, provide pre- and postoperative teaching. Include a significant other in teaching sessions. Reinforce the following information with written instructions: -Limitations such as avoiding reading, lifting, bending to pick up objects, strenuous activity, and sleeping on operative side Importance of not disturbing the eye dressing -Prescribed medications and side effects -Importance of follow-up appointments -Manifestations of postoperative complications such as eye pain, decreased visual acuity or other change in vision, headache, nausea, or itching and redness of the affected eye -Administration of eye drops and application of eye patch or shield -Care, insertion, and removal of contact lenses as appropriate -Visual changes associated with thick-lensed eyeglasses as appropriate Promote Wellness Care of the client in the community revolves around prevention. Advise all clients about the importance of wearing eye protection during potentially hazardous activities, such as welding, and about wearing sunglasses with UVA/UVB protection when outdoors. Discuss the link between heavy smoking and cataract development. Provide education to encourage clients to refrain from starting to smoke or to help them stop smoking. -Encourage clients with diabetes, previous history of visual problems, or disorders that require frequent use of corticosteroids to see an ophthalmologist at least every 2 years. -Encourage clients who smoke to enroll in a smoking cessation program. -Encourage all clients to use appropriate eye protection when using tools and when spending time outside. -Conduct an eye and vision assessment at each healthcare interaction with clients ages 65 years and older; inquire about any problems with vision and date of last appointment with an ophthalmologist or optometrist.

CP Prevention

Because maternal infection is associated with the development of pediatric CP, infection prevention, including maintaining good hand hygiene, is a primary goal. Keeping current with vaccinations is also a means by which a pregnant client can reduce the risk for having a baby born with CP. Injury prevention, including properly securing infants during motor vehicle travel and taking measures to prevent falls, serves to protect the child from brain trauma. Additionally, women at risk for pre-term labor should discuss methods of risk reduction with their healthcare provider. Some research suggests magnesium sulfate may reduce the risk of CP among surviving infants who are born preterm.

Focus on Diversity and Culture Cultural Background and the Prevalence of Blindness

Blindness affects African Americans more often than Caucasians and Hispanics. Glaucoma and cataracts are serious problems within the African American community and can lead to blindness. Beginning at age 40, African Americans should have a comprehensive dilated eye exam at least every 2 years. If there is also a diagnosis of diabetes, exams should be scheduled at least once a year. Unfortunately, due to disparities in access to health services, this population is less likely to seek preventive eye care. Nurses working with these clients should inquire about the frequency of eye examinations at each healthcare interaction.

Focus on Diversity and Deaf Culture

Deaf culture is a community that is shared by individuals who are deaf or hard of hearing, their family members, and others who self-identify with the deaf community. It is usually based on a shared proficiency in a common sign language. Members of Deaf culture consider deafness to be a matter of difference rather than disability. The United Nations Convention on the Rights of Persons with Disabilities declares that "Persons with disabilities shall be entitled, on an equal basis with others, to recognition and support of their specific cultural and linguistic identity, including sign languages and deaf culture"

Seizure Risk Factors

Infants are susceptible to developing epilepsy in the first year of life, with an incidence of 1 per 1,000. The incidence decreases with age. The median age for the development of epilepsy is 5-6 years of age. In the United States, approximately 150,000-325,000 children between 5 and 14 years of age have epilepsy. Other risk factors include an infant who is small for gestational age, presence of underlying neurological conditions, brain tumors or infections of the brain, stroke, cerebral palsy, autistic disorder, family history, or abuse of drugs.

Clinical Manifestations and Therapies Alzheimer Disease

Mild cognitive impairment CLINICAL MANIFESTATIONS: -Reduced concentration and memory lapses noticeable by others -Difficulty learning and remembering new things -Problems functioning in work or social settings -Frequently losing or misplacing important objects -Difficulties with planning and organization CLINICAL THERAPIES: -Use of cuing devices such as to-do lists, calendars, written schedules, and verbal reminders -Deliberate establishment of and adherence to daily routines -Counseling regarding possible retirement or withdrawal from the more challenging aspects of one's job Mild AD (early stages) CLINICAL MANIFESTATIONS: -Difficulty recalling recent events, personal history, or the current date -Trouble performing complicated mental calculations -Difficulty finding words -Problems performing complex ADLs, including shopping, preparing meals for others, and managing finances -Withdrawal from social situations and challenging mental activity -Increased moodiness, flat affect, or signs of depression and/or anxiety CLINICAL THERAPIES: -Continued use of cuing devices and established routines -Assistance with complex ADLs (may permit client to continue living independently) -Administration of anti-AD acetylcholinesterase inhibitors, including rivastigmine (Exelon), galantamine (Razadyne), and donepezil (Aricept) -Administration of SSRIs and/or anxiolytics to address mood-related symptoms -Occupational therapy -Consultation with a dietitian or nutritionist -Referral to community resources, support groups, and/or counseling services Moderate AD (middle stages) CLINICAL MANIFESTATIONS: -Inability to carry out less complex ADLs, such as preparing meals for oneself and choosing appropriate clothing -Loss of ability to live independently -Difficulty recalling one's address or phone number -Increased problems finding words and communicating clearly -Inability to recall information from recent memory -Increasing difficulty remembering details from remote memory -Disorientation to time and place -Increased tendency to become lost -Inability to perform less complex mental calculations CLINICAL THERAPIES: -Assistance with a wider range of ADLs -Continuation of earlier behavioral and pharmacologic therapies -Addition of anti-AD NMDA receptor antagonists, including memantine (Namenda) -Occupational, physical, and/or speech therapy -Institution of safety measures to help prevent injuries, wandering, and accidents Severe AD (late stages) CLINICAL MANIFESTATIONS: -Gradual inability to perform any ADLs, including bathing and toileting -Eventual urinary and fecal incontinence -Inability to identify family and caregivers -Extreme confusion and lack of awareness of one's surroundings -Gradual loss of remote memory and ability to speak -Inability to perform simple mental calculations -Dramatic personality changes, including extreme suspiciousness and fearfulness -Sundowning, delusions, compulsions, agitation, and violent outbursts -Gradual loss of ability to walk, sit unaided, and hold one's head up -Development of abnormal reflexes -Physical rigidity -Loss of swallowing ability CLINICAL THERAPIES: -Assistance with all ADLs -Continuation of earlier behavioral and pharmacologic therapies -Addition of atypical antipsychotics, as appropriate -Round-the-clock care and/or admittance to a skilled nursing facility -Frequent repositioning -Liquid nutrition or feeding tubes as appropriate -Respite care for family members and other caregivers

Peripheral Neuropathy Risk Factors

Risk factors for acquired peripheral neuropathies include the following: -Diabetes -Alcohol abuse -Vitamin deficiencies, particularly B vitamins -Immune system suppression -Autoimmune diseases -Kidney, liver, or thyroid disorders -Exposure to toxins, including some medications. Age also appears to have a role in risk for peripheral neuropathy. Studies show that the incidence of peripheral neuropathy increases significantly in older adults. A survey conducted in 1999 discovered that 8%-9% of Medicare recipients have a primary or secondary diagnosis of peripheral neuropathy. Although some changes in the peripheral system are due to the normal aging process, they are not usually associated with changes in functional status.

Peripheral Neuropathy Surgery

Surgical intervention may be appropriate when peripheral neuropathies are caused by compression, as in the case of nerve tumors, carpal tunnel syndrome, and peripheral nerve injuries. Neuropathies caused by medical pathologies cannot be treated with surgery.

ASD Nursing Process

Throughout application of the nursing process, the client's parents or caregivers will be integral team members. Because much of the assessment data is collected by way of interview, the nurse should prioritize the establishment of effective, open communication patterns with the client's primary caregivers and family members. Assessment The nurse may encounter the child with ASD when parents seek care for a suspected hearing impairment, speech difficulty, or developmental delay. Early and frequent developmental screening of all children can help in referral for thorough assessment and identification of cases. Parents may report abnormal interaction such as lack of eye contact, disinterest in cuddling, minimal facial responsiveness, and failure to talk. Be alert to observations by the parents that the baby or young child does not look at them or provide other developmental or behavioral cues. Initial assessment focuses on language development, response to others, and hearing acuity. Become familiar with the following "red flags" of the American Academy of Neurology and Child Neurology Society that require immediate evaluation: -No babbling or communication gestures by 12 months -No single word by 16 months -No spontaneous two words by 24 months -Loss of language or social skills previously achieved. Ask about birth history, including possible neonatal exposure to drugs or alcohol. Carefully evaluate the child for history of developmental milestones and refer for abnormalities. Perform developmental screening that considers several areas of development, including motor activity, social skills, and language, or refer the family to a professional or community resource that provides such screenings. Recall that the child may have normal performance in one area such as motor skills, but delayed development in another area such as language skills. Likewise, language may be normal for age, but social interactions delayed. Include questions about adaptive skills such as toilet training and feeding patterns. Inquire about school performance because some areas may be normal while others are delayed. Observe the child in play situations and evaluate the use of creative and exploratory play versus more repetitive patterns. Perform hearing and vision screening if possible to rule out sensory problems. When a child with a diagnosis of autistic disorder is hospitalized for a concurrent problem, obtain a history from the parents regarding the child's routines, rituals, and likes and dislikes, as well as ways to promote interaction and cooperation. Autistic children may carry a special toy or object that they play with during times of stress. Ask parents about these objects and their use. Ask about the child's behaviors and observe them on admission. Obtain a history of acute and chronic illnesses and injuries. Ask about eating patterns and food restrictions. Inquire about CAM in a nonjudgmental and supportive manner. Diagnosis Nursing diagnoses must be tailored to fit the individual needs of the child. Nursing diagnoses that may be appropriate for inclusion in the plan of care for pediatric clients with ASD include the following: -Risk for Injury -Impaired Verbal Communication -Impaired Social Interaction related to developmental disability -Risk for Caregiver Role Strain related to the chronic demands of child's condition -Compromised Family Coping Planning Nursing care focuses on preventing injury, stabilizing environmental stimuli, providing supportive care, enhancing communication, giving the parents anticipatory guidance, and providing emotional support. Appropriate outcomes for a child with ASD may include the following: -The child will remain free of injury. -The child will acquire communication strategies that enable communication with others. -The child will be able to perform self-care to maximum potential. -The child will demonstrate consistent developmental progress. -The child will participate in small group activities with family members or peers. -The child's symptoms will be managed successfully. Implementation Working with children with autism spectrum disorder and their families requires patience, sensitivity, and understanding. While some parents may be aggressive about seeking information and resources, others may be too overwhelmed and exhausted from caring for their child to do this. For these parents, the nurse may be the most important, most accessible, and most caring resource available to them. Nurses must take the time to provide client teaching and support and affirm parents' efforts to help their children. Prevent Injury Monitor autistic children at all times, including bath time and bedtime. Close supervision ensures that the child does not obtain any harmful objects or engage in dangerous behaviors. For the child who engages in head banging or other abusive behaviors, bicycle helmets and hand mitts can be the least restrictive method for providing safety. They enable the child to participate in activities and engage in a social environment to the degree possible. Provide Anticipatory Guidance Many children with autism spectrum disorders will require life-long supervision and support, especially if the disorder is accompanied by mental retardation. Some children may grow up to lead independent lives, although they will have social limitations with impaired interpersonal relationships. Encourage parents to promote the child's development through behavior modification and specialized educational programs. The overall goal is to provide the child with the guidance, education, and support necessary for optimal functioning. Stabilize Environmental Stimuli Children with ASD interpret and respond to the environment differently than other individuals. Sounds that are not distressing to the average individual may be interpreted by autistic children as louder, more frightening, and overwhelming. They may respond to different sounds or environments by withdrawing, crying, or using ritualistic behaviors such as arm-flapping, which may or may not be self-injurious. The child needs to be oriented to new settings such as a classroom or hospital room and may adjust best to a small classroom or a hospital room with only one other child. Encourage parents to bring the child's favorite objects from home. To avoid distressing the client, minimize relocation of objects within the environment. Provide Supportive Care Developing a trusting relationship with the autistic child is often difficult. Adjust communication techniques and teach to the child's developmental level. Ask parents about the child's usual home routines and maintain these routines as much as possible when the child is out of the home. Because self-care abilities are often limited, the child may need assistance to meet basic needs. When possible, schedule daily care and routine procedures at consistent times to maintain predictability. Identify rituals for nap time and bedtime and maintain them to promote rest and sleep. Integrate patterns that facilitate intake of nutritious foods at mealtimes. School programs and individualized education plan (IEPs) can help the child learn self-care skills. Parents are integral parts of the treatment team when the child's learning goals are established in early intervention or school programs. If the child is hospitalized, encourage parents to remain with the child and to participate in daily care planning. All clients with ASD need emotional support. Children who are developing successfully may face new challenges with the onset of the emotional and hormonal changes of adolescence. As social circles develop in middle and high school, the adolescent with autism may become more painfully aware of being different from other teenagers. The nurse may see this when a parent brings in a child after a scuffle at school or for help with increasing self-destructive behaviors as the child struggles to deal with the many changes. The nurse can provide crucial information about the physical changes adolescents experience and help the parent modify the plan of care to include opportunities for building new skills the child needs to navigate this difficult time. Enhance Communication Because children with autism have impaired communication skills, nursing care focuses on utilizing and improving communication with the child. Speech is used when possible; short, direct sentences are usually best. If the child responds well to visual cues, then pictures, computers, and other visual aids may form an important part of interaction. Some children are able to learn and communicate through sign language. Children with autism spectrum disorders benefit greatly from speech and language therapy. Encourage parents of these children to maintain close contact with speech therapists. Use of consistent communication techniques at home and at school provides further stability for the child and increases opportunities for successful communication. Facilitate Community-Based Care Families of autistic children need a great deal of support to cope with the challenges of caring for the autistic child. They experience the challenges of families who have a child with a chronic disorder. Participating in parent support groups and learning how to reframe the condition to view its positive aspects are helpful strategies. Many communities offer training programs for parents, in addition to support groups. Help parents identify resources for child care, such as special toddler programs and preschools. The child may need specialized transportation services or other social supports. The school-age child will need an individualized education plan (IEP). The parent or primary caretaker often has difficulty obtaining respite care and may need assistance to find suitable resources. Siblings of the autistic child may need help explaining the disorder to their friends or teachers. The nurse can be instrumental in assisting these siblings in understanding and explaining autism. Family support programs are available in some states to provide assistance to parents. Genetic counseling should be offered to the family. Information on immunizations is necessary because parents may have heard about a potential connection between immunization and the disorder. They should be encouraged to have the child immunized on the recommended schedule. Parents may have questions about where to find information on complementary and alternative therapies. Local support groups for parents of autistic children are available in most areas. Families can also be referred to the Autism Society of America for information.

Glaucoma Pharmacologic Therapy

Topical medications are effective for many clients. Which therapy is prescribed depends on a number of factors, including client health history. For example, beta-blockers are contraindicated for clients with heart failure, asthma, or COPD. To help doctors, pharmacists, and clients identify their glaucoma eye drops easier, the U.S. Food and Drug Administration has mandated that the tops of the eyedrops be color-coded. Topical beta-adrenergic blocking agents reduce intraocular pressure by decreasing the production of aqueous humor in the ciliary body. Beta-adrenergic blockers may be prescribed for use once or twice a day depending on the specific drug and dosage form. Selected beta-adrenergic blockers reduce intraocular pressure by decreasing the production of aqueous humor. Because beta-blockers do not affect pupil size and lens accommodation, they do not have the adverse effects on visual acuity that adrenergic agonists do. Their systemic effects, however, may limit their usefulness for certain clients. When administering beta-blockers or teaching about their use, remember that they can produce systemic effects, including bronchospasm, bradycardia, and heart failure. Drug examples: timolol (Timoptic) levobunolol (Betagan) carteolol (Ocupress) metipranolol (OptiPranolol) Mechanisms of Action: Decrease the production of aqueous humor in the eye, thus decreasing intraocular pressure. Nursing Considerations: Systemic absorption may occur; assess for hypotension, bradycardia, shortness of breath. Assess client for contraindications to beta-blocker medications (asthma, COPD, heart block, or heart failure). Teach client to close eye and occlude lacrimal duct after administration to help reduce systemic absorption. The prostaglandin analog drugs relax the ciliary muscle, improving the outflow of aqueous humor and reducing intraocular pressure. These drugs have the advantage of requiring only a single daily dose. However, they do have some adverse effects, such as blurred vision and stinging, and when used long term, they cause permanent darkening of the iris of the eye and eyebrows, increased growth of eyelashes, and conjunctival hyperemia (redness). Prostaglandin analogs such as latanoprost (Xalatan) are a newer class of ophthalmics used to increase aqueous outflow. They are similar to beta-blockers in that their longer duration of action means they require only a daily dose. Drug examples: latanoprost (Xalatan) bimatoprost (Lumigan) travoprost (Travatan) Mechanisms of Action: Increase drainage of aqueous humor through the uveoscleral pathway. Reduce intraocular pressure by about 30%. Nursing Considerations: Client may experience change in iris color. Blurred vision, eye pain, eye redness may be noted by the client. Adrenergic agonists dilate the pupil, reduce the production of aqueous humor, and increase its absorption, effectively reducing intraocular pressure in open-angle glaucoma. The adrenergic agonist brimonidine may be prescribed along with a beta-blocker or in cases when beta-blockers are contraindicated. Another adrenergic agonist, apraclonidine, may be prescribed when other drugs do not sufficiently reduce intraocular pressure, but adverse effects make it inappropriate for long-term use. The side effects have led to a reported 15% discontinuation rate. Drug examples: brimonidine tartrate (Alphagan) apraclonidine (Iopidine) Mechanism of Action: Decrease production of aqueous humor in the eye and increase drainage of aqueous humor through the uveoscleral pathway. Nursing Considerations: Assess client for contraindications such as acute angle-closure glaucoma, hypertension, CAD, and dysrhythmias. Assess for CNS side effects such as anxiety, nervousness, and muscle tremors. Allergic reactions are common with this class of drug; assess for eye and eyelid erythema. The carbonic anhydrate inhibitors lower intraocular pressure and are used primarily as adjunctive therapy. Dorzolamide and brinzolamide are administered as eyedrops, whereas acetazolamide may be given orally, intramuscularly, or intravenously. Dorzolamide (Trusopt), a carbonic anhydrase inhibitor, decreases the production of aqueous humor and reduces intraocular pressure. It is used with other drugs to control pressures and in clients for whom beta-blockers are contraindicated because of heart failure or reactive airway disease. Acetazolamide (Diamox), a systemic carbonic anhydrase inhibitor, also may be used for some clients. Drug examples: acetazolamide (Diamox): oralmedication methazolamide (Neptazane): oral medication brinzolamide (Azopt) dorzolamide (Trusopt) Mechanism of Action: Decrease the production of aqueous humor into the eye. Related to sulfa drugs. Nursing Considerations: Oral medications may cause periorbital numbness and tingling in the fingers and toes. May cause loss of potassium; assess daily weight, electrolytes. Allergy to sulfa is a contraindication. Use with caution in clients with renal or hepatic disease. In acute angle-closure glaucoma, diuretics may be administered intravenously to achieve a rapid decrease in intraocular pressure prior to surgical intervention. Both the carbonic anhydrase inhibitor acetazolamide and osmotic diuretics, such as mannitol, are used. Fast-acting miotic drops, such as acetylcholine, also are administered to constrict the pupil and draw the iris away from the angle and from the canal of Schlemm. Miotic Drug examples: pilocarpine (Isopto Carpine, Pilopine, Pilostat) carbachol (Isopto Carbachol) Mechanism of Action: Increase drainage of aqueous humor through the trabecular meshwork via pupillary constriction. Nursing Considerations: Rarely used routinely due to side effects. May be beneficial in narrow-angle glaucoma. Myopic clients have increased risk of retinal detachment. Assess for headaches, eye pain, and dim vision, especially in low light. The role of the nurse in teaching clients to recognize side effects of these medications is critical. The nurse should ensure that the client has been instructed on and understands how to properly instill eye drops.

Glaucoma Nursing Process

When planning and providing nursing care for the client with glaucoma, nurses must consider the specific form of the disease and its actual or potential effects on the client's vision, lifestyle, safety, and psychosocial well-being. In the hospitalized client, glaucoma is typically a concurrent diagnosis rather than the primary reason for seeking care, unless the diagnosis is acute angle-closure glaucoma. Although glaucoma cannot be prevented, its severity and potentially deleterious permanent effects can be limited with early visual screening. The nurse assumes an important role in educating the public about the risk factors for glaucoma and encouraging clients over the age of 40 to receive an eye examination every 2-4 years that includes tonometry screening. Those with a predominant family history or another risk factor, such as frequent use of corticosteroids, should be evaluated more frequently, every 1-2 years. After the age of 65, yearly ophthalmological examinations are recommended. Assessment Collect the following data through a health history and physical examination: Health history. Family history; presence of altered vision, halos, and excessive tearing; sudden, severe eye pain; use of corrective lenses; most recent eye examination; history of chronic illness; medication history. Physical examination. Distant and near vision, peripheral fields, retina for optic nerve cupping. Diagnosis Nursing care planning focuses on problems associated with the temporary or permanent visual impairment, the resultant increased risk for injury, and the psychosocial problems of anxiety and coping. Potential diagnoses include the following: Risk for Injury Risk for Ineffective Self Health Management Anxiety Planning Appropriate outcomes for the client with glaucoma include the following: -The client will follow glaucoma care guidelines and have no further vision loss. -The client will remain free from injury. -The client will report control over environment and reduced anxiety. Implementation Whether glaucoma and resulting impaired vision is the client's primary problem or a preexisting condition in a client with another disorder, it must be a primary consideration in nursing care planning. Prevent Injury The following measures help ensure the client's safety while providing mobility and helping prevent complications associated with immobility: -If the client's vision loss is unilateral and recent, provide instructions related to unilateral vision loss and change in depth perception as follows: >Caution the client about the loss of depth perception and teach safety precautions such as reaching slowly for objects and using visual cues as to distance, especially when driving. >Teach the client to scan, turning the head fully toward the affected side to identify potential hazards and looking up and down to compensate for the loss of depth perception. The client with a unilateral vision loss is often unaware of its effect on peripheral vision and depth perception. Clients who are experiencing a sudden loss of vision due to acute angle-closure glaucoma or are experiencing significant visual impairment due to inadequately managed chronic glaucoma face increased risk for injury. Clients who have had surgical interventions for glaucoma are at even greater risk. >Assess the client's ability to perform activities of daily living. Clients may be reluctant to request assistance, believing that they should be able to perform these familiar tasks. Carefully assessing and providing needed assistance helps prevent injury and maintain the client's self-esteem. >Discuss possible adaptations in the home to help the client remain as independent as possible and to prevent falls or other injuries. Often minor changes in the home environment, such as removing scatter rugs and small items of furniture, allow the client to navigate safely in this already familiar environment. For the hospitalized client: >Notify housekeeping and place a sign on the client's door to alert all personnel not to change the arrangement of the client's room. The client with impaired vision is at high risk for falling in an unfamiliar environment. It is important to maintain a safe, familiar room. >Raise two or three side rails on the client's bed. Raised rails remind clients to ask for assistance before ambulating in an unfamiliar environment. Facilitate Orientation and Environmental Modifications -Address the client by name and identify yourself with each interaction. Orient the client to time, place, person, and situation as indicated. State the purpose of your visit. The client with impaired vision must rely on input from the other senses. A lack of visual cues increases the importance of verbal ones. For example, the client with impaired vision cannot see the nurse checking an intravenous infusion and needs a verbal explanation of who is in the room and why. When the client's normal daily routine is disrupted by illness or hospitalization, additional sensory input such as a radio, a television, and explanations of the routine and activities is useful to maintain the client's orientation. -Provide any visual aids that are routinely used. Keep them close to the client, making sure the client knows where they are and can reach them easily. Easy access encourages the client to use these items and enhances the ability to provide self-care. -Orient the client to the environment. In the hospital setting, explain the location of the call bell, personal items, and furniture in the room. If the client is able, provide a tour of the client's room, including the bathroom and sink. Clients with visual impairments are usually capable of providing self-care in a known environment. -Provide other tools or items that can help compensate for diminished vision, as follows: >Bright, nonglare lighting >Books, magazines, and instructions in large print >Books on tape >Telephones with oversize push buttons >A clock with numbers and hands that can be felt. -Assist with meals by: >Reading menu selections and marking choices. >Describing the position of foods on a meal tray according to the clock system. For example, "On the plate, the peas are at 9 o'clock, the mashed potatoes are at 1 o'clock, and the chicken breast is at 6 o'clock. The milk glass is at 2 o'clock on the tray above the plate, and coffee is at 11 o'clock." >Placing the utensils in a readily accessible position. >Removing lids from containers, buttering the bread, and cutting meat as needed. >Feeding the client or providing continued assistance as needed during the meal if the client's visual impairment is new or temporary. Providing assistance during eating is important to maintain the client's nutritional status. The client may be ashamed of needing help or embarrassed to request it and may respond by not eating or by claiming not to be hungry. -As needed, assist with mobility and ambulation as follows: >Have the client hold your arm or elbow and walk slightly ahead as a guide. >Do not hold the client's arm or elbow. >Describe the surroundings and progress as you proceed. Warn in advance of potential hazards, turns, and steps. >Teach the client to feel the chair, bed, or commode with the hands and the back of the legs before sitting. Promote Psychosocial Wellness The actual or potential loss of sight threatens the client's self-concept, role functioning, patterns of interaction, and, potentially, environment. The client with impaired vision who functions well in a familiar environment will feel anxious in the unfamiliar setting of a hospital or care facility. -Assess for verbal and nonverbal indications of anxiety level and for normal coping mechanisms. Repeated expressions of concern or denial that the vision change will affect the client's life indicate anxiety. Nonverbal indicators include tension, difficulty concentrating or thinking, restlessness, and changes in vocalization (rapid speech, quivering voice). Physical indicators include tachycardia, dilated pupils, cool and clammy skin, and tremors. The client may not recognize this feeling as anxiety. Identifying and acknowledging the anxiety can help the client recognize and deal with it. -Encourage the client to verbalize fears, anger, and feelings of anxiety. Verbalizing helps externalize the anxiety and allows fears to be addressed. Discuss the client's perception of the eye condition and its effects on lifestyle and roles. -Discussion provides an opportunity to correct misperceptions and introduce alternative activities and assistive devices for clients with visual impairments. -Identify coping strategies that have been useful in the past and adapt these strategies to the present situation. Previously successful coping strategies may be employed to increase the client's sense of control.

Case Management

describes a range of models for integrating healthcare services for individuals or groups. Generally, case management involves multidisciplinary teams that assume collaborative responsibility for assessing needs, planning and coordinating, implementing, and evaluating care for groups of clients from pre-admission to discharge or transfer and recuperation. A case manager may be a nurse, social worker, or other appropriate professional. In some areas of the United States, case managers may be referred to as discharge planners. The care management model focuses on the needs of the integrated delivery system. It has many similarities to case management, in that it includes planning, assessment, and coordination of health services. The client focus is population based instead of based on an individual client. The population might be the entire population, members of a managed care plan, or could be a specific group with similarities, such as clients with diabetes. The goal of the care management model is to integrate a continuum of clinical services. Care management is not only concerned with medical care but also with health promotion, disease prevention, costs, and use of resources. Case management is often used within the care management model. Typical tools used to facilitate care management are critical pathways, disease management programs, and benchmarking. Case management may be used as a cost containment strategy in managed care. Both case management and managed care systems often use critical pathways to track client progress. A critical pathway is a standardized plan that helps track care provided to clients with similar, predictable medical conditions. Critical pathways are also called critical paths, clinical path- ways, interdisciplinary plans, anticipated recovery plans, interdisciplinary action plans, and action plans. Responsibilities of Case Managers -Assessing clients and their homes and communities -Coordinating and planning client care -Collaborating with other health professionals -Monitoring clients' progress -Evaluating client outcomes The Nurse as Case Manager Nursing case management organizes client care by major diagnoses or diagnosis-related groups (DRGs). DRGs allow nurses to work toward predetermined client outcomes within specific time frames and resources. Nursing case management requires the following: -Collaboration of all members of the healthcare team -Identification of expected client outcomes within specific time frames -Use of principles of continuous quality improvement (CQI) and variance analysis -Promotion of professional practice. Research suggests that case management has been particularly successful in disability management, especially when applied to helping injured employees to return to work. Likewise, home care and ambulatory settings lend themselves to case management. The case manager, who may be called a care coordinator, usually does not provide direct client care but rather coordinates and monitors the care provided by licensed and unlicensed care providers. Client involvement and participation is key to successful case management. In an acute care setting, the case manager has a caseload of 10-15 clients and follows the clients' progress through the system from admission to discharge, accounting for variances from expected progress. Nursing case managers on a client care unit may coordinate, communicate, collaborate, problem-solve, and facilitate client care for a group of clients. Ideally, nursing case managers have advanced degrees and considerable clinical experience in nursing. To initiate case management, specific client diagnoses that represent high-volume, high-cost, and high-risk cases are selected. High-volume cases are those that occur frequently, such as total hip replacements on an orthopedic floor. High-risk cases include clients or case types who have complications, stay in a critical care unit longer than 2 days, or require ventilatory support. Clients also may be selected because they are being treated by a physician who supports case management. Whatever client population is selected, baseline data must be collected and analyzed. These data provide the information necessary to measure the effectiveness of case management. Essential baseline data include length of stay, cost of care, and complication information. Five elements are essential to successful implementation of case management: 1. Support by key members of the organization (administrators, physicians, nurses) 2. A qualified nurse case manager 3. Collaborative practice teams 4. A quality management system 5. Established critical pathways. When a specific client population is selected to be "case managed," a collaborative practice team is established. The team, which includes clinical experts from appropriate disciplines (e.g., nursing, medicine, physical therapy) needed for the selected client population, defines the expected outcomes of care for the client population. Based on expected client outcomes, each member of the team, using that member's discipline's contribution, helps determine appropriate interventions within a specified time frame. In case management, all professionals are equal members of the team; thus, one group does not determine interventions for other disciplines. All members of the collaborative practice team agree on the final draft of the critical pathways, take ownership of client outcomes, and accept responsibility and accountability for the interventions and client outcomes associated with their discipline. The emphasis must be on managing client outcomes and building consensus among team members. Outcomes must be specified in measurable terms.

Seizure Clinical Therapies for Children

Children with febrile seizures are usually not treated with an anticonvulsant at the time of the seizure because these seizures typically abate before arrival at the emergency department or clinic. Acetaminophen is given to lower the child's temperature. Long-term anticonvulsants are not recommended for simple febrile seizures. Diazepam may be ordered for rectal or oral administration at the onset of a child's febrile illness when the parents are severely anxious about a subsequent febrile seizure. Any child with a generalized seizure lasting longer than 10 minutes needs to be monitored for electrolytes, glucose, blood gases, increasing fever, and abnormal blood pressure. Most seizure disorders are managed with anticonvulsants, which may be given intravenously or rectally. For children, a single medication (monotherapy) is preferred for seizure control to minimize the potential for adverse effects such as sleepiness and difficulty with speech. An additional antiepileptic may be used only if seizure control is not achieved with the first medication. The child should be monitored for continued motor activity and the potential for status epilepticus (a continuous seizure that lasts for more than 30 minutes or a series of seizures during which consciousness is not regained). The postictal period ranges from 30 minutes to 2 hours. Serum drug levels are monitored to achieve therapeutic levels or to identify whether toxicity is possible. When tolerated, therapeutic ranges of medications may be exceeded to control seizures. Medication dosage adjustments are often needed in pediatric clients as the child grows. The physician should provide a seizure action plan for any child with a history of seizure activity who attends school or day care or who is cared for outside the home while the parents work. Nurses can assist parents in making sure that teachers and caregivers understand the action plan and know when and how to use it. Approximately 25%-30% of children have refractory or intractable seizures, seizures that continue to occur even with optimal medical management. These children should be referred to an epilepsy center for other potential treatments, such as a ketogenic diet, vagal nerve stimulation, or evaluation for surgical treatment. A ketogenic diet is occasionally used for children under the age of 8 years with myoclonic and absence seizures. This diet involves a high intake of fat (up to 80% of calories), an adequate intake of protein (1 g/kg), and a very low intake of carbohydrates. The medium-chain triglyceride (MCT) ketogenic diet is used extensively for treating refractory childhood epilepsy. This diet increases the plasma levels of medium straight-chain fatty acids. The child usually begins the diet in the hospital with a fast for 24 hours. The ketosis caused by the diet is believed to produce anticonvulsant effects. The diet is customized to the child to maintain the ideal body weight, maximize ketosis, and achieve optimal seizure control. Motivation must be high for the family to prepare the food and maintain the child on the diet for several years; improved seizure control is directly related to compliance with the diet. The child's urine ketone values are monitored weekly or more frequently. The most common complications are constipation, hyperlipidemia, and kidney stones. Constipation can be treated with MCT oil and increased fluids. Kidney stones are treated by increasing fluid intake and alkalinizing the urine. A trial of antiepileptic medication withdrawal is often attempted for children who have been seizure free for 2 years, with medications tapered slowly over a period of months. Approximately 70% remain seizure free after 2 years; if seizures do recur, they normally do so within the first year after AED withdrawal.

Delirium vs Dementia

Dementia is a progressive loss of cognitive function. It is not a specific disease, but rather a set of symptoms caused by various disorders that affect the brain. Dementia is sometimes confused with delirium, but it is critical to distinguish between the two. While delirium is an acute and reversible syndrome, dementia is the steady, irreversible loss of global brain function. delirium is acute. Remember that dementia is chronic. But both present with the same types of confusion

Seizure Prevention

Everyone has a seizure threshold. When this threshold is exceeded, a seizure may occur. Some individuals have abnormally low seizure thresholds, increasing their risk for seizure activity. Others may experience seizures as the result of a pathological process, such as epilepsy. Prevention of seizures is difficult, but there are some steps individuals can take to reduce their risk for seizures or reduce the frequency of seizure activity. Individuals with epilepsy often experience seizure activity on exposure to a trigger. Triggers may be individualized (e.g., odors, flashing lights). General triggers include fatigue, hypoglycemia, fever, alcohol, hyperventilation, and menstruation. Individuals who are able to identify triggers may succeed in reducing their frequency. Maintaining good self-care (e.g., maintaining the therapeutic regimen, avoiding alcohol, eating properly, and balancing rest and activity) is important for individuals with seizure disorders.

ADHD Risk Factors

Genetic factors are implicated in the development of ADHD. Although ADHD occurs more commonly within families (25% have a first-degree relative with the disorder), a single gene has not been located and a specific mechanism of genetic transmission is not known. It is believed that a genetic predisposition interacts with the child's environment, so that both factors contribute to the appearance of the condition. Family stress, poverty, and poor nutrition may be contributing factors in some cases. Daily television exposure at ages 1-3 years is associated with attentional problems at 7 years.

Evidence-Based Practice Glaucoma and Exercise

Problem The number of Americans with glaucoma is estimated to be more than 2.2 million. Eyedrops that help to lower intraocular pressure are a primary treatment for glaucoma, but evidence suggests that around only 30% of clients can properly instill eyedrops. More Americans are also turning to alternative and complementary medicine. An estimated 38% of adults have used some form of alternative treatment. It has been suggested that exercise can help with glaucoma. Evidence A recent study measured intraocular pressure of 25 participants without glaucoma using tonography prior to exercise, after the participants walked 1,046 meters (3,431 feet) at a brisk pace, and again after a 20-minute rest period. The exercise reduced the intraocular pressure by a significant amount immediately after exercise and the 20-minute rest period. Another study had a combination of 145 participants, some with glaucoma (45) and some without (100). It also introduced the use of various antiglaucoma eyedrops in both study groups. Intraocular pressure was measured using tonography prior to exercise and 5 minutes after 10 minutes of exercise on a cycle ergometer. A statistically significant decrease in intraocular pressure was found in all groups. Aerobic and resistance exercise was studied in a group of 21 healthy participants. Aerobic exercise was performed on a cycle ergometer for 30 minutes and resistance exercise included leg curl and butterfly machines. Tonography measurements were taken prior to exercise, during exercise, and 10 minutes after exercise. There was a statistically significant decrease in intraocular pressure during aerobic exercise, but not during resistance exercise. Implications Studies have shown that aerobic exercise can reduce intraocular pressure and may benefit clients with glaucoma. Clients should be counseled that certain exercises that involve inversion (scuba diving, bungee jumping, and certain yoga poses) or Valsalva maneuver (weight lifting or yoga or Pilates without proper breathing techniques) may be harmful because they increase intraocular pressure. Additionally, the effects of decreased intraocular pressure are only gained if the client continues to exercise regularly. The benefits may be lost after 2 weeks of not exercising.

Hearing Impairment Risk Factors

About 50% of hearing loss in children is genetically caused, usually with a recessive inheritance pattern with GJB2 gene abnormalities. Another 25% is due to environmental causes around the time of birth; the remainder is due to unknown causes. Although many infants with hearing loss have no known risk factors, identified risks include the following: Family history of congenital hearing loss Positive titer for TORCH infections (toxoplasmosis, rubella, cytomegalovirus, syphilis, herpes) Craniofacial abnormalities Very low birth weight (<1500 g) Bilirubin greater than 16 mg/dL Aminoglycoside medication administration for more than5 days Low Apgar score at 1 or 5 minutes Bacterial meningitis Mechanical ventilation for over 5 days Presence of syndromes associated with hearing loss (Down syndrome, Pierre Robin syndrome, Arnold-Chiari malformation).

Angle-Closure Glaucoma

Acute angle-closure glaucoma (also called narrow-angle or closed-angle glaucoma) is the other, less common form of primary glaucoma in adults. It occurs between 1 and 40 times for every 1,000 Americans with a higher incidence among certain ethnic groups. Narrowing of the anterior chamber angle occurs because of corneal flattening or bulging of the iris into the anterior chamber. When the lens thickens during accommodation or the iris thickens during pupil dilation, this angle can close completely. Closure of the angle blocks the outflow of aqueous humor through the trabecular meshwork and canal of Schlemm, and the intraocular pressure rises abruptly. This increase in intraocular pressure damages the neurons of the retina and the optic nerve, leading to a rapid and permanent loss of vision if not treated promptly. Episodes of angle-closure glaucoma are typically unilateral. However, a history of angle-closure glaucoma of one eye increases the risk that it will occur in the other eye. Because of the effect of pupil dilation on aqueous outflow in angle-closure glaucoma, episodes often occur in association with darkness, emotional upset, or other factors that cause the pupil to dilate. Clients may have intermittent episodes lasting several hours before they have a more typical prolonged attack of angle-closure glaucoma. Clients with a history of the condition must avoid medications, such as atropine and other anticholinergics, that can cause mydriasis, or dilation of the pupil.

Dementia Risk Factors

Although genetic factors contribute to some cases of dementia, the exact degree and mechanism of involvement vary by type of dementia. For example, researchers know that many cases of early-onset Alzheimer disease (which manifests before age 65) are caused by three heritable gene mutations. If an individual carries one of these mutations, her children have a 50% chance of inheriting the disease. In contrast, late-onset Alzheimer disease exhibits a more complex pattern of inheritance. Scientists continue to identify genes that increase risk, but none of these genes directly cause the disease. Thus, while children of individuals with late-onset Alzheimer disease have an increased likelihood of illness, the condition is not inevitable. Other forms of dementia also exhibit varying patterns of heritability. Frontotemporal dementia clearly runs in families, as about one third of affected individuals have two or more relatives with the disease. The role of genetics in vascular dementia and dementia with Lewy bodies is less obvious. Researchers have yet to identify any genes that directly cause either disorder, although they suspect some risk factors may be passed from generation to generation. Beyond genetics, other non-modifiable risk factors for dementia include age, gender (with women slightly more likely to be affected), diabetes, Parkinson disease, multiple sclerosis, Down syndrome, kidney disease, HIV, and some learning disabilities

ADHD Non-pharmacologic Therapy

Although medications are an important part of the treatment plan for the client with ADHD, nonpharmacologic therapies are also integral components of care. Environmental modification and behavioral therapy can greatly improve outcomes for the client with ADHD and enhance their daily quality of life. ENVIRONMENTAL MODIFICATION Children with ADHD often benefit from environmental changes. Decreasing stimulation by turning off the television, keeping the environment quiet, and maintaining an orderly and clutter-free desk or study area may help the child to stay focused on the task at hand. Another relatively simple change is appropriate classroom placement, preferably in a small class with a teacher who can provide close supervision and a structured daily routine. Consistent limits and expectations should be set for the child. Children living in chaotic homes and communities may function better if the environment can be simplified. When aggressive behaviors occur, therapeutic approaches such as play and group therapy may be useful. BEHAVIORAL THERAPY Behavioral therapy involves rewarding the child for desired behaviors and applying consequences for undesirable behaviors. Children may be rewarded by praise or earn points toward a movie or another desired outing for staying seated during meals or quietly listening in a classroom. Cues are established so that a child can subtly be reminded when impulsive or hyperactive behaviors are escalating. Behavioral therapy is most effective when all adults who are in close contact with the child, such as parents and teachers, are involved in and supportive of the program.

Autism Spectrum Disorder Patho and Etiology

Although the etiology of ASD is unknown, it is believed to be associated with a complex interplay between genetic, immunologic, and environmental factors. Current research is investigating the role of environmental exposure to certain drugs during pregnancy; the role of neurotransmitters such as dopamine and serotonin, which are abnormal in some children with ASDs; and other factors. As discussed in the module on Immunity, no link has been found between mercury-containing vaccinations and autism spectrum disorders.

Macular Degeneration Risk Factors

Although the exact cause of AMD is unknown, factors associated with it include aging, smoking, race, cardiovascular health, and possibly genetic factors. Caucasians have a significantly higher risk of developing AMD than do African Americans, Hispanics, and people of Asian ancestry. However, the destructive changes in the macula occur most often as a response to the aging process. AMD affects males and females equally. Evidence suggests that the risk for developing AMD may be reduced by consumption of certain antioxidant nutrients, including vitamin C, vitamin E, beta-carotene, and zinc.

ASD Prevention

Although there is no way to prevent autism, some factors can be modified to reduce the risk of occurrence, maternal health being the most important. Women who are pregnant should be counseled to avoid use of tobacco products and exposure to secondhand smoke; refrain from drinking alcohol or using illegal substances; and disclose the pregnancy to any healthcare provider, including their pharmacist, when they learn they are pregnant.

Dementia Common Etiologies Table 23-4

Alzheimer disease CAUSE AND PRIMARY PATHOPHYSIOLOGY Form of dementia that causes problems with memory, thinking, and behavior. Although the cause is unknown, the disease clearly involves two types of brain abnormalities: amyloid plaques and neurofibrillary tangles. Alzheimer disease is progressive, worsening with time. Vascular dementia CAUSE AND PRIMARY PATHOPHYSIOLOGY Involves brain damage from circulatory problems, mainly stroke. May also arise when blood vessels in the brain are damaged by chronic disorders like extreme hypotension. (Note: Vascular brain changes frequently coexist with other conditions, such as Alzheimer disease.) Dementia with Lewy bodies (DLB) CAUSE AND PRIMARY PATHOPHYSIOLOGY A progressive dementia that results from abnormal deposits that accumulate in brain cells. Called Lewy bodies, these deposits kill the cells over time. The cause of DLB is usually unknown, although it sometimes seems to run in families. Frontotemporal dementia (FTD) CAUSE AND PRIMARY PATHOPHYSIOLOGY A group of disorders caused by progressive cell degeneration in the frontal or temporal lobes. As nerve cells degenerate, brain tissue shrinks. Some affected individuals develop neurofibrillary tangles.

Alzheimer's disease Deane's Notes

Alzheimer's disease is a progressive, irreversible loss of cognitive function that may be caused by several conditions and disorders. There is no official known cause of Alzheimer's- practitioners must rely on their assessment skills and patient histories to make a diagnosis. There are no blood tests, and no scans that can diagnose it while the patient is living. It can only be officially diagnosed on autopsy. There is no cure for Alzheimer's disease. There are medications that can help slow the progression of the disease. The earlier these medications are started, the better. It is also important to note that these drugs will not have the same effect forever. As the disease progresses, the client may need the medication dose increased. Eventually as the client reaches the later stages of Alzheimer's, the medications will have no effect on the client.

Table 18-4 Ototoxic Medications

Aminoglycosides Drug examples: -tobramycin -gentamicin -amikacin These drugs are used in the treatment of advanced bacterial infections and tuberculosis. Hearing loss is more likely to occur in clients with renal disease or previous hearing difficulty. Loop Diuretics Drug examples: -Bumex -Lasix These drugs are diuretics that affect the ascending limb of the loop of Henle in the kidney. Non-steroidal Anti-InflammatoryDrugs (NSAIDs) Drug examples: -ibuprofen -naproxen -salicylates These are some of the most commonly used drugs in our society today. They can be used as antipyretics, analgesics, and anti-inflammatory agents and for their anti-platelet effects. Ototoxic effects are likely to occur with higher doses. Medications can also cause hearing disorders. The decision to discontinue a medication based on potential for ototoxicity should be made in collaboration with the prescribing physician. Some drugs cannot be discontinued despite their potential to damage hearing. The nurse should be aware of medication groups that can cause hearing damage and teach clients to monitor their hearing while they are taking these medications. One group requires special mention: platinum coordination complexes (cisplatin). These drugs are used in the treatment of many solid cancerous tumors, and are the most ototoxic and widely prescribed drugs in clinical practice.

Medications Macular Degeneration

Antiangiogenic Drugs Drug examples: aflibercept (Eylea) pegaptanib (Macugen) ranibizumab (Lucentis) Mechanism of Action: Block vascular endothelial growth factor (VEGF). VEGF stimulates angiogenesis and vasculogenesis and causes blood vessels to grow in the retina, which causes damage. Useful in treating wet form of AMD. Nursing Considerations: Must be given by injection into the eye. Teach clients to be aware of and seek treatment for serious side effects: eye pain, erythema, edema, photophobia, headache, confusion, weakness or numbness. Antiangiogenic drugs are the primary therapy used in the treatment of wet AMD. These drugs must be injected into the eye by a physician. Vascular endothelial growth factor (VEGF) causes growth of abnormal blood vessels in the macula, causing the visual changes associated with AMD. Antiangiogenic drugs block the production of VEGF, thus slowing the progression of the disease.

Seizure Pharmacologic Therapy

Antiepileptic drugs (AEDs), also called anticonvulsant drugs, can reduce or control most seizure activity. More than 20 drugs are available for use in the treatment of epilepsy. These medications do not cure the disorder; they only manage its manifestations. AEDs generally act in one of two ways: by raising the seizure threshold or by limiting the spread of abnormal activity in the brain. The goals of medications for epilepsy are to protect the client from harm and to reduce or prevent seizure activity without impairing cognitive function or producing undesirable side effects. Ideally, the lowest possible dose of a single medication that will control the client's seizures is prescribed; often, however, several medications must be tried before the most effective one is identified, and a combination of drugs may be needed to manage the client's seizures. Status epilepticus is a continuous seizure that lasts for more than 30 minutes or a series of seizures during which time consciousness is not regained. It requires immediate intervention to preserve life. Establishing and maintaining the airway is a priority. A solution of 50% dextrose is administered intravenously to prevent hypoglycemia. Diazepam (Valium) or lorazepam (Ativan) is given intravenously, and if necessary, the dose is repeated in 10 minutes to stop seizure activity. Phenytoin (Dilantin) is administered intravenously for longer-term control of seizures. Phenobarbital also may be administered to clients in status epilepticus. Antiepileptic Drugs (AEDs) Drug examples: phenytoin (Dilantin) phenobarbital primidone (Mysoline) carbamazepine (Tegretol) valproic acid (Depakene) ethosuximide (Zarontin) clonazepam (Klonopin) gabapentin (Neurontin) lamotrigine (Lamictal) tiagabine HCl (Gabitril) Mechanism of Action: These drugs act in the motor cortex of the brain to reduce the spread of electrical discharges from the rapidly firing epileptic foci in this area. These agents control seizures without impairing the normal functions of the CNS. Monitor blood pressure, pulse, and respirations. Note evidence of CNS side effects such as blurred vision, dimmed vision, slurred speech, nystagmus, or confusion. Gingival hyperplasia may be noted in clients taking phenytoin. Recognize that if clients are to be on prolonged therapy, they may need a diet rich in vitamin D. Therapies: Monitor the serum calcium level as ordered; phenytoin can contribute to demineralization of bone. When administering anticonvulsants intravenously, monitor closely for respiratory depression and cardiovascular collapse. Administer gabapentin 2 hours after antacids. Administer tiagabine HCl with food.

Glaucoma Patho and Etiology

Aqueous humor, a thick fluid, occupies the anterior and posterior chambers of the eye. The normal intraocular pressure of approximately 12-15 mmHg is maintained by a balance between the production of aqueous humor in the ciliary body, its flow through the pupil from the posterior to the anterior chamber of the eye, and its outflow or absorption through the trabecular meshwork and canal of Schlemm. When this balance is disrupted, usually because of a decrease in the outflow or absorption of aqueous humor, intraocular pressure increases. Although the exact relationship is unclear, it appears that increased intraocular pressure injures the optic nerve. Axons in the periphery of the optic disc are damaged first. As optic fibers are destroyed, the rim of the optic disc shrinks and the normal depression in its center (the optic cup) becomes larger and deeper (called optic "cupping"). These changes to the optic disc are visible before changes in the visual field can be detected. As the disease progresses, the individual experiences a painless, progressive narrowing of the visual field and eventual blindness. Vision loss is often significant before the client seeks treatment and glaucoma is diagnosed. Primary glaucoma in adults has two major forms: open-angle glaucoma and angle-closure glaucoma. Both terms refer to the angle formed at the point where the iris meets the cornea in the eye's anterior chamber. Pediatric glaucoma can fall into one of two categories: primary or secondary. Primary congenital glaucoma occurs in about 1 in every 10,000 births in the United States. It is caused by an abnormal development in the ocular drainage system. Approximately 10% of cases are diagnosed at birth, with the majority (80%) diagnosed by age 1. Secondary congenital glaucoma may or may not have genetic origins. It results from disorders of the eye or the body. Secondary glaucoma can occur in adults as well. It can develop in individuals who have been on long-term steroid therapy or as the result of an eye injury.

Dementia Prevention

Because the causes of dementia vary, a number of preventive actions can help reduce the risk of disease. Similarly, various screening methods may be appropriate depending on what form of dementia an individual has. Several modifiable factors can increase an individual's risk of dementia, including: -Medical conditions that are preventable or remediable (e.g., cardiovascular disease) -Environmental, psychological, and interpersonal traits and behaviors (e.g., repeated head trauma) -Depression in older adults To reduce risk, individuals should follow their treatment plans for medical conditions. Consuming fruits and vegetables is especially important, because they contain vitamins and antioxidants believed to help prevent dementia. Weight control and smoking cessation improve cardiovascular function, and limiting alcohol consumption reduces dementia risk. Use of personal protective equipment while cycling and participating in contact sports also reduces the likelihood of head trauma. Engaging in regular social activity can help prevent depression, especially in older adults. Moreover, social activity itself decreases dementia risk, as does taking part in mental activities like reading, games, and puzzles. No specific screenings for dementia exist, in part because the condition has so many different causes. The most effective way to screen individuals is to simply observe them in their daily lives. Early signs of dementia include difficulty finding words, as well as regularly forgetting recent events and everyday information. As the disease progresses, many individuals undergo mood changes and are often agitated or scared about their symptoms. With time, more deficits start to emerge, but they appear so gradually that they are frequently overlooked or wrongly attributed to normal aging. Often, affected individuals deny having any cognitive problems whatsoever. All older adults should be monitored for dementia, but some require closer screening. Individuals who have experienced stroke or head trauma should undergo regular cognitive assessment, as should individuals with a family history of Alzheimer disease. Individuals from families with early-onset Alzheimer disease may also opt for screenings that look for the three genes implicated in this condition

Hearing Impairment Prevention

Both the loudness of the noise and the length of exposure contribute to hearing damage. The level of noise is measured in decibels (dB). The louder the noise, the higher the decibel level. The use of ear buds and head phones in young children puts them at a higher risk of hearing loss. Permanent damage can occur at volumes louder than 85 dB. Although young children may be at higher risk, hearing impairment associated with the use of ear buds and head phones can affect individuals of any age group. Due in part to the popular practice of listening to portable media devices (e.g., MP3 players and cellular phones), noise-induced hearing loss (NIHL) continues to be a serious public health concern. This condition is associated with prolonged exposure to sounds of greater than or equal to 85 dB over an extended time period, including listening to loud music. NIHL may also be caused by a single exposure to an intense impulse sound at a volume of 120 dB or more, such as an explosive blast. Prevention of NIHL includes avoiding situations that pose known risks and wearing ear protection when in environments that may involve exposure to known risks. Warning signs that may suggest auditory damage include the inability to hear another individual's voice from a distance of 3 feet away and muffled sound perception. Ringing in the ears (tinnitus) and ear pain are warning signs, as well.

Cataracts Clinical Manifestations

Cataracts tend to occur bilaterally unless related to eye trauma. Fortunately, they tend to develop at different rates, and one cataract generally matures more rapidly than the other. As a cataract interferes with light transmission through the lens, visual acuity decreases, affecting both close and distance vision. Light rays are scattered as they pass through the lens, causing complaints of glare. Glare affects the ability to adjust between light and dark environments. Color discrimination is impaired, particularly in the blue to purple range. When the cataract is mature, the pupil may appear cloudy gray or white rather than black. The diagnosis of a cataract is made based on the history and eye examination. Ophthalmoscope examination confirms the diagnosis by identifying the location and extent of a cataract. As the cataract matures, ophthalmoscopy reveals a dark area instead of the red reflex.

Lifespan Considerations Adults With ASD

Childhood ASD persists into adulthood. Children who receive timely intervention and whose parents and treatment teams collaborate to find the best treatment for them as individuals have the greatest chance of becoming successfully functioning adults. Adults with ASD continue to struggle with communication skills, especially understanding nonverbal communication and socialization. These clients are most successful when they seek employment opportunities and activities that play to their strengths. Many communities provide job training and supervised work programs for adults with ASD. Many adults with less severe ASD are active community members, becoming fully employed and living independently. Others need more support and may choose to continue to live with their parents or to reside in a group living environment that provides additional support. A number of government programs exist to assist these individuals with financial support. Information on these programs is available from the Social Security Administration. Unfortunately, research on adults with ASD is lacking, especially for the geriatric population. Few clinics exist that specifically treat adults with ASD, making it challenging for these adults to get the best level of care. Many adults with ASD who cannot function independently or whose families can no longer provide care for them end up being financially subsidized by the state. With the steady rise in the number of children diagnosed with this disorder comes a resulting increase in the number of adults with the disorder. The financial impact on state governments is significant and is likely to increase steadily for many years. This is all the more reason why children with ASD need to be identified early, so that they may have access to treatments and therapies that give them the best chance to become fully functioning adults.

Lifespan Considerations Seizures

Children -Children and adolescents need to have medications adjusted as they grow and medication plasma levels monitored carefully in order to maintain the level within therapeutic range to obtain optimal effects. -The child and parents need to be educated about medication regimens. Explain the purpose of each drug, schedule for administration, side effects, and importance of giving all doses. Teaching the older child to take medications without parental intervention gives the child a feeling of control. -Regular dental care is important because of the effect of phenytoin on the gingiva. -The parents of children with recurrent febrile seizures should be taught how to administer antipyretics properly. Parents need to know, however, that antipyretics may not prevent a febrile seizure associated with an acute illness. The potential toxicity of an anticonvulsant in a child with febrile seizures is often considered greater than the risk of the seizures, and parents can be reassured that complications from febrile seizures are rare. -The family should receive help in working with school administrators to develop an Individualized Healthcare Plan so the child can receive needed medications and care during school hours. -Physical activity and exercise are important for all children. Encourage the child's participation in sports when adequate supervision is provided. Children who are prone to seizures require one-to-one supervision during swimming and water activities. -The child may be afraid of having a seizure in front of friends. Reassure the child and family that taking medications regularly should control seizures. -Summer camps for children with seizures can be a safe and comfortable place for the child to enjoy outdoor activities. Talk with parents about communicating with camp administrators and sharing health and action plans as they do with school administers. Adolescents and Adults -Depending on state laws, most clients with seizure disorders can drive after they have been seizure free for at least 2 years. -Adolescent females need to be educated about the potential teratogenicity of some anticonvulsants, such as valproic acid and carbamazepine, which are associated with neural tube defects and heart defects. Until pregnancy is desired, contraception should be used when the adolescent is sexually active. -Some antiepileptic medications cause a drug interaction with oral contraceptive pills that can lead to contraceptive failure. Effective contraception may require increasing the amount of estrogen in the contraceptive hormones or using medroxyprogesterone injections. -Families should be taught about safety guidelines. Families of clients with severe seizure disorders need to develop an emergency care plan so that emergency personnel know about the need for care in advance.

ADHD Clinical Manifestations

Children with ADHD have problems related to decreased attention span, impulsiveness, and/or increased motor activity. Symptoms can range from mild to severe. The child has difficulty completing tasks, fidgets constantly, is frequently loud, and interrupts others. Sleep disturbances are common. Because of these behaviors, the child often has difficulty developing and maintaining social relationships and may be shunned or teased by other children. This only increases the anxiety of the already compromised child, whose behavior is set on a downward-spiraling course. Typically, girls with ADHD show less aggression and impulsiveness than boys, but far more anxiety, mood swings, social withdrawal, rejection, and cognitive and language problems. Girls tend to be older at the time of diagnosis. Manifestations: Symptoms of ADHD fall into three groups: Hyperactivity, Impulsive behavior, Lack of attention Clinical Therapies: -Make environmental modifications. -Reduce environmental stimuli. -Encourage planned seating in classrooms, group settings. -Promote consistent limit setting. -Behavioral therapy: Reward appropriate behavior. Apply timely, appropriate consequences for inappropriate behavior. Teach strategies to improve focus, coping. -Medications

ADHD Pharmacologic Therapy

Children with moderate to severe ADHD are treated with pharmacotherapy. The psychostimulant methylphenidate (Ritalin, Concerta) is most often prescribed. Paradoxically, in clients with ADHD, this medication helps to improve focus and attention, as opposed to yielding increased hyperactivity. A skin patch that releases medication over a 9-hour period is now available, facilitating ease of administration. Usually, a favorable response (a decrease in impulsive behaviors and an increase in the ability to sit still and attend to an activity for at least 15 minutes) is seen in the first 10 days of treatment and frequently with the first few doses. Other medications that may be used include dextroamphetamine (Dexedrine or Adderall), dexmethylphenidate, and atomoxetine. All of these medications are Schedule II drugs, which means that a monthly prescription must be obtained from a healthcare practitioner. Side effects include headaches, insomnia, tachycardia, and anorexia. A child's growth pattern should be carefully monitored while taking these medications. A "drug holiday," during which the child does not take the medication during weekends or over school breaks, can be considered and discussed with the prescribing provider. Currently, one non-psychostimulant medication has been approved for treatment of ADHD. Atomoxetine (Strattera) was originally developed as a drug to treat depression, but studies did not support this use. It was found to be beneficial in treating symptoms of ADHD. One major side effect that clients and their parents should be aware of is the increased risk of suicidal ideation. It can also cause nausea and hepatic dysfunction. Liver function should be monitored while taking this medication. It should be used with caution in clients with heart disease or a family history of heart disease especially with long-QT syndrome or arrhythmias. Ritalin Side Effects- Irritability, dizziness, palpitations, euphoria, insomnia, tachycardia, weight loss, application site reactions (Daytrana) Serious Adverse Effects - Sudden death, dependence, psychosis

Alzheimer's Disease Nonpharmacologic Therapy

Clients with AD can benefit from a range of nonpharmacologic interventions. Individuals who are starting to experience language deficits may be able to slow this decline by working with a speech therapist. Similarly, physical therapy can help individuals improve their muscle tone, maintain coordination, and maintain their range of motion. Occupational therapy may be appropriate, especially for clients in the earlier stages of the disease, because it can help them maintain the ability to perform many activities of daily living. Clients and their caregivers may also benefit from referral to community organizations. Government agencies and social workers may be able to assist with such things as receiving disability benefits, obtaining assistive devices, and securing transportation. AD advocacy groups such as the Alzheimer's Association can link families with a range of other community-based resources, including adult daycare centers, caregiver respite services, long- term care facilities, legal assistance, and support groups.

Client Teaching Managing Glaucoma at Home

Clients with glaucoma must be provided with strategies for managing the disease at home. They need to understand the importance of lifetime therapy to control the disease and prevent blindness. If a permanent visual impairment has resulted, the client needs information on achieving maximum independence while maintaining safety. The following topics should be discussed with the client and family: -Importance of not taking certain prescription and over-the-counter medications without consulting a physician -Prescribed medications, including proper way to administer eyedrops -Periodic eye examinations with measurement of intraocular pressure -Risks, warning signs, and management of acute angle-closure glaucoma -Possible surgical options -Community resources such as the National Association for Local Societies of Visually Impaired People, local libraries, and transportation services -Helpful resources such as the Glaucoma Foundation, Young and Under Pressure, the Glaucoma Research Foundation, and Prevent Blindness America.

Peripheral Neuropathy Clinical Manifestations

Clinical manifestations of peripheral neuropathy depend on the affected nerve or nerves and the amount of damage. The primary goal of treatment is to correct or manage the underlying cause so that symptoms are controlled and further nerve damage is minimized. The client with polyneuropathy commonly has distal paresthesias; pain described as aching, burning, or shooting; and feelings of cold feet. Other manifestations may include impaired sensations of pain, temperature, light touch, two-point discrimination, and vibration. With GBS, there is frequently a "stocking-glove" pattern—feeling as though stockings and gloves are being worn when they are not—with pain in the hands, feet, and legs. Weakness in the arms or legs is often caused by damage to motor nerves; clients may report difficulty walking or running, stumbling, dropping things, and tiring easily. A general feeling of lack of coordination or clumsiness may be reported, and the client may compensate by changing the walking pattern to maintain balance. Charcot-Marie-Tooth syndrome, the most common inherited peripheral neuropathy in the world, is characterized by a slowly progressive degeneration of the muscles of the foot, lower leg, hand, and forearm. Symptoms usually present between adolescence and young adulthood.

Hearing Impairment Clinical Manifestations

Conductive hearing loss involves an equal loss of hearing at all sound frequencies. If the level of sound is greater than the threshold for hearing, speech discrimination is good. Because of this, the client with a conductive hearing loss benefits from amplification by a hearing aid. Therapies: Hearing aid, Treat underlying conditions such as otitis media, Steroids and/or decongestants to reduce inflammation, Surgery Sensorineural hearing losses typically affect the ability to hear high-frequency tones more than low-frequency tones. This loss makes speech discrimination difficult, especially in a noisy environment. Hearing aids are often not useful, because they amplify both speech and background noise. The increased sound intensity may actually cause discomfort for the client. Therapies: Cochlear implant Because the hearing loss of presbycusis is gradual, the client and family may not realize the extent of the deficit. The individual with a hearing impairment may be described as unsociable or paranoid. The family may worry that the individual is becoming increasingly forgetful, absentminded, or perhaps "senile." Depression, confusion, inattentiveness, tension, and negativism have been noted in older adults with hearing impairments. Functional problems such as poor general health, reduced mobility, and impaired interpersonal communication are also associated with hearing loss. Caregivers need to be alert for signs of impaired hearing such as cupping an ear, difficulty understanding verbal communication when the individual cannot see the speaker's face, difficulty following conversation in a large group, and withdrawal from social activities. Hearing aids and other amplification devices are useful for most clients with presbycusis. Therapies: Hearing aid, Steroids or decongestants to reduce inflammation

Table 18-5 Communication Techniques for Clients Who Have a Hearing Impairment

Cued speech Supplement to lip reading; eight hand shapes represent groups of consonant sounds and four positions about the face represent groups of vowel sounds; based on the sounds the letters make, not the letters themselves; client can "see-hear" every spoken syllable a hearing person hears. Oral approach Uses only spoken language for face-to-face communication; avoids use of formal signs; uses hearing aids and residual hearing. Total communication Uses speech and sign, finger-spelling, lip-reading, and residual hearing simultaneously; client selects communication technique depending on the situation. Sign language A separate language that allows the user to communicate quickly and accurately with others who understand signs. The signs or hand movements represent words or concepts. When a sign is not available, the word can be spelled out using signs. American Sign Language (ASL) is most often used; however, British Sign Language (BSL) is common in Europe.

ADHD Diagnostic Tests

Diagnosis begins with a careful history of the child, including family history, birth history, growth and developmental milestones, behaviors such as sleep and eating patterns, progression and patterns in school, social and environmental conditions, and reports from parents and teachers. A physical examination should be performed to rule out neurological diseases and other health problems. The mental health specialist then tests the child and administers questionnaires to the parent and teacher. It is important to identify other conditions that may mimic ADHD or exist in conjunction with the disorders. These conditions may include depression, anxiety, learning disorder, conduct disorder, or oppositional defiant disorder. Specific diagnostic criteria must be applied to all children with the potential diagnosis of ADHD. Behaviors at home and school or at day care must be evaluated because abnormal patterns in two settings are needed for diagnosis. A variety of tests are available for the trained professional to use in establishing the diagnosis. Based on the findings, desired outcomes are established for the child's performance and management of the disorder. Treatment is established to meet the desired behavioral outcomes and includes a combination of approaches, such as environ- mental changes, behavior therapy, and pharmacotherapy. Treatment is expected to be long term. Children are usually brought for evaluation when behaviors escalate to the point of interfering with the daily functioning of teachers or parents. When children have learning disabilities or anxiety disorders, the problem is commonly misdiagnosed as ADHD without further evaluation of the child's symptoms. Obtaining an accurate diagnosis by a pediatric mental health specialist is vital. Careful management of ADHD in childhood may lead to better social functioning later in life.

ASD Nonpharmacologic Therapy

Early intervention assists in maximizing the child's potential by improving developmental skills, decreasing severity of symptoms, and establishing helpful support for parents. Children are taught how to focus and apply learning. Treatment focuses on behavior management to reward appropriate behaviors, foster positive or adaptive coping skills, and facilitate effective communication. The goals of treatment are to reduce rigidity or stereotypy (repetitive, obsessive, machinelike movements) and other maladaptive behaviors.

Table 11-7 Management of Status Epilepticus

Emergency assessment and management -Maintain a patent airway. Muscle rigidity may compromise the airway. -Perform a jaw-thrust maneuver if the airway is obstructed. -Keep suction equipment at the bedside in case secretions are excessive. -Give oxygen by mask, because increased metabolic demands deplete oxygen stores. -Monitor vital signs and circulation with pulse oximeter and cardiorespiratory monitor. -Perform neurological assessment. Ongoing urgent medications -Establish an intravenous line to administer any necessary fluids or management. -Administer glucose if the child is hypoglycemic; the physical stress of the seizure may result in declining glucose levels. -Insert a nasogastric tube. -Protect the child from injury. -Manage thermoregulation. Medications -Administer benzodiazepines such as diazepam, lorazepam, or midazolam. If there is no response, the dose may be repeated. Phenytoin or phenobarbital may be necessary if seizure activity continues. Cumulative doses of drugs may produce apnea, so be prepared to assist with ventilations.

Focus on Diversity and Culture Seizures

Epilepsy has been misunderstood and stigmatized over centuries and across cultures. The violent nature of convulsions and their sudden onset has caused many to fear epilepsy or attribute it to supernatural causes. In some Asian and Oceanic regions, some people regard epilepsy as a psychiatric disorder. Nurses must assess whether there are any cultural barriers that may affect the care of a patient with any illness, not just epilepsy. They should approach the subject with respect and sensitivity to cultural differences.

Clinical Manifestations and Therapies Cataracts

Etiology: Congenital cataracts -Rare -Usually unknown cause -May occur with other birth defects such as: -Congenital rubella -Trisomy 21 (Down syndrome) -Pierre Robin Syndrome -Trisomy 13 (Patau syndrome) Manifestations: May be different from age-onset cataracts. Gray or white cloudy pupils. May have nystagmus. May not have "red eye" glow in photos. Therapies: Diagnosis confirmed by ophthalmologist. Treatment depends on severity. If mild and doesn't seem to affect vision, it may just be monitored, especially if bilateral. If moderate to severe and seems to affect vision or if unilateral, surgical removal is usually recommended. In most cases an intraocular lens is also implanted at the time of surgery. Etiology: Age-related cataracts -Aging causes proteins in the lens to deteriorate and become cloudy. -By age 75, most people will have cataracts that affect vision. -Factors that speed formation: -Diabetes -UVA/UVB exposure -Smoking -Family history Manifestations: Cloudy/opaque lens. May cause cloudy vision, halos, diplopia, or photophobia. Therapies: Early cataracts or those with minimal effect on vision may require no surgical intervention. Encourage UVA/UVB protection. Utilize safety measures for decreased visual acuity. Surgery is recommended if cataract interferes with ADLs.

Alzheimer's Disease Risk Factors

For the majority of individuals with AD, it's impossible to trace their disease to any one source. However, a variety of factors appear to increase the risk of developing AD. Age is among the most prominent risk factors. Statistics show that as individuals age, their likelihood of suffering from AD increases dramatically. In fact, whereas only 13% of all individuals age 65 and older have the disease, approximately 45% of individuals age 85 and older are affected. Still, it is important to note that AD and other forms of dementia are not a normal part of the aging process. Family history and gender also increase the odds of AD. As mentioned, a small number of AD cases are directly traceable to certain inherited genes. However, most cases are believed to involve gene variants that increase an individual's risk but do not directly cause the disease. This theory is supported by the fact that individuals with one or more first-degree relatives with AD are at higher risk of developing the disease. Being female also appears to increase an individual's risk, although this may be partially because women tend to live longer than men. Not all AD risk factors have to do with age or inherited characteristics. Individuals who experience moderate head injury are twice as likely to develop AD, and individuals who experience severe head trauma have roughly 4.5 times the normal risk. AD is also more likely to affect individuals who have frequent yet comparatively mild head injury, such as football players and boxers. The connection between head trauma and AD remains unclear, although it may involve increased levels of amyloid protein and/or various inflammatory processes. In fact, emerging research suggests that inflammation is a major contributor to many brain changes associated with AD. Research has also implicated cardiovascular disease as a risk factor, most likely because it impedes the transport of oxygen and nutrients to brain tissue. It is important to note that some factors previously linked to AD are no longer considered problematic. Exposure to alu-minum, aspartame, dental fillings, and flu vaccine have all been ruled out as potential contributors

Lifespan Considerations Epilepsy in Older Adults

For years, epilepsy was believed to be a disease that principally affected children. However, some 570,000 adults over the age of 65 suffer from epilepsy. Epilepsy increases risk of falls and broken bones and can threaten the independence of the older adult. These data have important implications for nursing assessments and care. -The most common cause of epilepsy in older adults is arteriosclerosis of the cerebrovascular system. -The most common type of seizure in older adults is a complex partial seizure. -Older adults tend to have longer postseizure manifestations than do younger adults. -Epilepsy that begins in older adults is often easier to control with antiepileptic drugs (AEDs) than that in younger people. However, some AEDs decrease the effect of statins used to treat arteriosclerosis (the most common cause of epilepsy in older adults).

Glaucoma Risk Factors

Glaucoma is a leading cause of blindness worldwide. Age and race are the primary identified risk factors. Glaucoma is 6 to 8 times more likely to occur in African Americans than in Caucasians, and it is about 15 times more likely to cause blindness in African American than in Caucasians. The prevalence of glaucoma rises rapidly in Mexican Americans over age 60. People of Asian descent are at higher risk. Clients with an immediate family member with glaucoma have a 9 times higher chance of developing the disease. Long-term steroid use may be a contributing factor. Prior eye injuries, especially blunt trauma or penetrating injuries, may cause secondary glaucoma years later.

Open-Angle Glaucoma

Glaucoma is usually a primary condition without an identified cause. Open-angle glaucoma, often called chronic simple glaucoma, is the most common form in adults, accounting for approximately 90% of all glaucomas. Its cause is unknown; it is thought to have a hereditary component, but no clear inheritance pattern can be identified. Open-angle glaucoma occurs more frequently in Latinos and African Americans; cardiovascular disease or diabetes may contribute to its formation. Open-angle glaucoma tends to be a chronic, gradually progressive disease. It typically affects both eyes, although the pressures and progression may not be symmetric. In open-angle glaucoma, the anterior chamber angle between the iris and cornea is normal (thus the term open angle). However, the flow of aqueous humor through the trabecular meshwork and into the canal of Schlemm is relatively obstructed; the cause of this obstruction is unknown. The trabecular meshwork increasingly inhibits the outflow of aqueous humor, and the intraocular pressure gradually increases. The result is neuronal ischemia and optic nerve degeneration, leading to gradual loss of vision.

Peripheral Neuropathy Diagnostic Tests

In addition to a medical history and neurological exam, diagnostics for peripheral neuropathy may include thefollowing: -Electromyography -Complete blood count (CBC) -Thyroid function tests -Serum levels for B12 and thiamin -Metabolic panel -Urine screening -Nerve biopsy. Lyme disease and HIV tests also may be indicated.

Macular Degeneration Non-pharmacologic Therapy

In its early or intermediate stages, the progress of dry AMD can be slowed through the use of high-dose antioxidants and zinc. Research demonstrated a benefit when vitamin C, vitamin E, beta-carotene (vitamin A), zinc, and copper were administered daily. Assistive devices that may be helpful to clients include magnifiers, large-print books and magazines, and high-intensity lighting to help the client cope with the reduced vision of macular degeneration. Computers and handheld electronic devices, such as iPads and Kindles, allow users to increase text size for easier reading and come equipped with audio functionality, which enables use of audiobooks and podcasts. Talking clocks or watches may also be helpful.

Glaucoma Clinical Manifestations

In many cases of open-angle glaucoma, there are no symptoms. Vision will even remain normal for a while. Then, as the nerve becomes more damaged, blank spots will start to appear in the visual field. Almost 50% of clients with glaucoma will not have high intraocular pressure on examination, so a single pressure reading may miss the diagnosis. An optic nerve examination is an essential part of a comprehensive eye examination. Symptoms such as experiencing severe eye and face pain, general malaise, nausea and vomiting, seeing colored halos around lights, and experiencing an abrupt decrease in visual acuity are associated with acute episodes of angle-closure glaucoma. The conjunctiva of the affected eye may be reddened and the cornea clouded with corneal edema. The pupil may be fixed (nonreactive to light) at midpoint. Congenital glaucoma can be more difficult to diagnose. Parents and healthcare professionals should be alert for photophobia, excessive tearing, and larger than normal eyes. The increase in intraocular pressure can stretch the elastic tissue of the cornea, making the eyeball appear larger.

Focus on Diversity and Culture Glaucoma

Individuals who have anatomically narrow anterior chambers, such as Inuits and other indigenous people and Asians, have higher rates of angle-closure glaucoma. Although angle-closure glaucoma is typically free of symptoms, it can cause intermittent pain or photophobia (sensitivity to light). The incidence of angle-closure glaucoma increases with age as the lens swells related to the aging process

Lifespan Considerations Manifestations of GBS in Children

Infants Infants have an onset of rapidly progressive severe hypotonia, possible respiratory distress, irritability, and feeding difficulties. Children -Older children exhibit rapidly progressive symmetric weakness and muscle pain with varying degrees of distal paresthesia and numbness in the legs. This ascending weakness spreads to the upper extremities, trunk, chest, neck, face, and head. Deep tendon reflexes may be diminished or absent. The child may develop acute ataxia or an inability to walk. -Difficulty swallowing and facial weakness are signs of impending respiratory failure. Respiratory effort may be inadequate for proper ventilation. -Cranial nerves may be affected, causing Bell's palsy, for example. A dysfunctional autonomic nervous system may cause such symptoms as a labile blood pressure and cardiac rate, postural hypotension, or profound bradycardia.

Hearing Impairment Surgery

Reconstructive surgeries of the middle ear, such as a stapedectomy or tympanoplasty, may help restore hearing with a conductive hearing loss. Stapedectomy is the removal and replacement of the stapes. This procedure is used to treat hearing loss related to otosclerosis. In a tympanoplasty, the structures of the middle ear are reconstructed to improve conductive hearing deficits. Chronic otitis media with necrosis and scarring of the middle ear is a common indication for this type of surgery. In myringotomy, a small hole is made in the tympanic membrane and then tympanostomy tubes are placed. This procedure is common among young children with repeated episodes of otitis media but can also be performed on older adults for chronic presence of middle ear fluid (effusion). The tubes allow equalization of air within the middle ear or prevent fluid accumulation. For the client with a sensorineural hearing loss, a cochlear implant may be the only hope for restoring sound perception. The cochlear implant consists of a microphone, speech processor, transmitter, receiver/stimulator, and electrodes. Its function is more similar to the way the ear normally receives and processes sounds than it is to that of a hearing aid. The microphone picks up sounds, sending them to the speech processor, which selects and processes those that are useful. The receiver/stimulator and transmitter receive signals from the speech processor, convert them to electrical impulses, and send these impulses to the electrodes for transmission to the brain. Cochlear implants provide sound perception but not normal hearing. The client is able to recognize warning sounds such as automobiles, sirens, telephones, and doors opening or closing. Clients also receive stimuli to alert them to incoming communication so they can focus on the individual speaking. Many clients learn to interpret perceived sounds as words, especially when the hearing loss is acquired as an adult.

Seizures Patho and Etiology

Seizures are believed to be the result of abnormal excessive concurrent electrical discharges from the cortical neuronal network of cells on the surface of the brain. Chemical changes in the neurons create an electrical negativity that enables the transfer of information between neurons. When an excessive number of these cells become excited, they discharge abnormally. These cells can be triggered by environmental or physiological stimuli (e.g., emotional stress, anxiety, fatigue, infection, or metabolic disturbances). Acute insults such as a CNS infection, hypoxia, and brain trauma are the most common causes of seizures in children. Focal seizures (also known as partial seizures) are caused by abnormal electrical activity in one hemisphere or in a specific area of the cerebral cortex, most often the temporal, frontal, or parietal lobes. The seizure may spread regionally, and the symptoms are related to the region of the cortex that is affected. In contrast, generalized seizures are the result of diffuse electrical activity that often begins in both hemispheres of the brain simultaneously, then spreads throughout the cortex into the brainstem. As a result, movements and spasms displayed by the client are bilateral and symmetric. Etiology Some seizures are idiopathic, that is, not provoked by known stimuli. Genetic factors may lower the seizure threshold by making brain cells more vulnerable to abnormal electrical discharges. Acquired seizures may be caused by underlying pathological conditions such as trauma, infection, hypoglycemia, hypotonic dehydration, electrolyte imbalance, endocrine dysfunction, toxins, tumors, or lesions that may be manifested at any time. Febrile seizures are generalized seizures that usually occur in children as the result of a rapid temperature rise above 39°C (102°F), usually in association with an acute illness. No evidence of intracranial infection or other defined cause is found. Febrile seizures are usually seen between 3 months and 5 years of age, with a peak incidence between 17 and 24 months of age. There is often a family history of febrile seizures. In addition, children who have one febrile seizure have a 30%-50% greater chance of having future seizures. The lower convulsive threshold of infants may explain this type of seizure. Febrile seizures are generally divided into two types: simple and complex. They affect all ethnic groups, but happen more frequently in some. They occur in 6%-9% of Japanese children, 5%-10% of Indian children, and 2%-5% of children in the United States and Western Europe

ASD Complementary and Alternative Therapy

Some parents who have a child with autism choose to use complementary and alternative medicine (CAM), such as touch therapy or a gluten-free diet, in an attempt to help the child. It is important to note that CAM therapies have not been adequately evaluated; therefore, there is an insufficient research base to support or refute them individually or as a whole. One approach includes dietary therapy with vitamin A, vitamin C, vitamin B6, magnesium, and omega-3 fatty acids. The use of gluten-free or casein-free diets has gained popularity in recent years. Parents have tried drug therapies that include secretin, a pancreatic gastrointestinal peptide, and Pepcid or other antacids. Some parents believe that detoxification by limiting certain dietary intake or using Epsom salt baths can be helpful. Nurses can help parents evaluate studies on complementary care and encourage parents to initiate only one treatment at a time; the effectiveness of any one treatment cannot be measured properly if it is initiated in conjunction with other therapies. At each healthcare interaction, the nurse working with a client with ASD should ask about therapies being used and discuss safeguards to avoid any undesired side effects.

Glaucoma Surgery

Surgical management of chronic open-angle glaucoma involves improving the drainage of aqueous humor from the anterior chamber of the eye or decreasing aqueous humor production. Surgical options include goniotomy, trabeculectomy, combined trabeculotomy with trabeculectomy, and trabeculotomy ab externo. Trabeculoplasty and trabeculectomy filtration surgery are the most commonly used procedures. In a laser trabeculoplasty, an argon laser is aimed through a gonioscope to create multiple laser burns spaced evenly around the trabecular meshwork. As the burns heal, the scars they create cause tension, stretching and opening the meshwork. This noninvasive technique requires no incision and can be performed as an outpatient procedure, making it the treatment of choice. Trabeculectomy is a type of filtration surgery in which a permanent fistula is created to drain aqueous humor from the anterior chamber of the eye. A portion of trabecular meshwork is removed, and a flap of sclera is left unsutured to create a channel, or fistula, between the anterior chamber and the subconjunctival space. Aqueous humor drains into the space under the conjunctiva, where it can be absorbed into the systemic circulation. A trabeculectomy is usually performed under general anesthesia and requires hospitalization. If these procedures are not effective, photocoagulation using an argon laser (heat) or cyclocryotherapy using a probe to freeze tissue may be employed to destroy portions of the ciliary body. This destruction of tissue reduces the production of aqueous humor, subsequently reducing intraocular pressure. Another surgical procedure involves inserting a glaucoma drainage device that regulates the outflow of aqueous humor. Surgical procedures used in the treatment of acute angle-closure glaucoma include gonioplasty, laser iridotomy, and peripheral iridectomy. Because of the high risk for a future attack of angle-closure glaucoma in the unaffected eye, these procedures are often performed prophylactically. In gonioplasty (also known as iridoplasty), the healing and scarring of microscopic lesions created at the periphery of the iris draw the iris away from the cornea, widening the anterior chamber. This widening of the chamber increases the angle and opens drainage channels for aqueous humor. Laser iridotomy is a noninvasive procedure in which a laser is used to create multiple small perforations in the iris of the eye. These perforations allow aqueous humor to drain from the posterior chamber to the anterior chamber and out through the trabecular meshwork and the canal of Schlemm. During an iridectomy, a small segment of the iris is removed to facilitate the flow of aqueous humor between the posterior and anterior chambers and to open the anterior chamber angle.

Cataracts Patho and Etiology

The incidence of cataracts within the population is so common that even if it is not the primary diagnosis, most nurses will take care of clients who have either had cataracts or had them surgically removed at some point in their life. Nurses should recognize that not all cataracts need to be removed in the early stages, but many clients will eventually have them surgically corrected. The majority of cataracts form as a result of the aging process. As the lens ages, its fibers and proteins change and degenerate. The proteins clump, clouding the lens and reducing light transmission to the retina. This process generally begins at the periphery of the lens, gradually spreading to involve the central portion. As the cataract continues to develop, the entire lens may become opaque. When only a portion of the lens is affected, the cataract is called immature. A mature cataract is opacity of the entire lens. In addition to clouding, the lens may discolor over time, affecting the ability to accurately discriminate colors. Etiology The prevalence of cataracts in the United States increases rapidly with aging. Approximately 50% of individuals between the ages of 65 and 74 will develop a cataract; that increases to 70% of individuals over the age of 70. Men are affected less frequently than women. African Americans with cataracts lose their vision at a rate twice that of Caucasians, due to lack of or delay in treatment. Additionally, four types of cataracts occur independent of the aging process. Secondary cataracts can form after surgery to treat another eye disorder, such as glaucoma, or as an effect of medication or another primary disorder. Clients who require regular or recurring doses of corticosteroids, for example, are at risk for secondary cataracts. Traumatic cataracts may result from an injury to the eye. Radiation cataracts may result from long-term exposure to radiation. Congenital cataracts may appear in a child at birth or in childhood, usually in both eyes.

Macular Degeneration Patho and Etiology

The macula is the area of the retina that provides sharp central vision, which it does by receiving light from the center of the visual field. Two forms of AMD are identified, a nonexudative (dry) form and an exudative (wet) form. Although both are progressive disorders, their manifestations and management differ. Nonexudative, or dry, macular degeneration is the more common form of AMD. It is the early or intermediate stage of AMD and accounts for 90% of all cases. Nonexudative macular degeneration begins with the accumulation of deposits called drusen beneath the pigment epithelium of the retina. Over time, these deposits enlarge and increase in number. The pigment epithelium detaches in small areas and becomes atrophic, interfering with sensory function of the macula. Typically, vision loss is not significant, and the disorder progresses slowly. However, there is a risk that the disorder will progress to an exudative stage of the disease. Exudative macular degeneration (wet) is characterized by the formation of new, weak blood vessels in the potential space between the choroid (vascular layer of the eye) and the retina (neurosensory layer). These new vessels are prone to leak, elevating the retina from the choroid and distorting vision. Although exudative macular degeneration typically is a gradual process, bleeding can lead to acute vision loss in some cases. All clients with exudative macular degeneration had the intermediate stage of the dry form first. With significant or repeated bleeding episodes, scar tissue forms and central vision is permanently lost. Luckily, this form only accounts for about 10% of all cases of AMD. Etiology Approximately 15 million Americans have AMD, with approximately 200,000 new diagnoses occurring each year. AMD is the number one cause of severe vision loss and legal blindness in Americans over the age of 60. There are indications that the risk for AMD is much lower for Asians, leading credence to the theory that diet and sun exposure may play a role, because Asians typically have an aversion to sun exposure and have diets high in dark leafy greens. Darker pigmentation also may play a part, because those with darker skin are less likely to develop AMD.

ADHD Patho and Etiology

The pathophysiology of ADHD is unclear, but some brain characteristics provide clues. Some children may have a deficit in the catecholamines dopamine and norepinephrine, which lowers the threshold for stimuli input. The disorder is marked by a delay in brain maturation in the areas of self-regulation. Increased input from stimuli and decreased self-regulation cause the hallmark inability to inhibit stimuli and motor activity. Some children exhibit additional problems such as aggressive behaviors, learning disabilities, and motor disorders. Etiology Although a variety of physical and neurological disorders are associated with ADHD, children with identifiable causes represent a small proportion of this population. ADHD may result from several different mechanisms involving interaction of genetic, biologic, and environmental risk factors. Examples of known associations include exposure to high levels of lead in childhood and prenatal exposure to alcohol or tobacco smoke. Other prenatal factors associated with a higher incidence of ADHD include preterm labor, impaired placenta functioning, and impaired oxygenation. Seizures and serious head injury are other potential associations.

Peripheral Neuropathy Nonpharmacologic Therapy

There is no specific treatment for polyneuropathy, because it is a symptom with many potential causes. The primary goals of treatment are to care for and manage the underlying cause. However, a combination of medication, lifestyle modifications, and physical therapy can be effective in treating symptoms and increasing quality of life. Physical or occupational therapy may help the client maintain mobility and avoid further changes in functional status. Changes in daily life may be required to maintain or restore health. These include: -Compliance with therapeutic regimen for primary condition (e.g., maintain blood glucose control) -A healthy, well-balanced diet (vitamin supplements may be necessary) -Maintenance of optimal weight -Regular exercise to increase/maintain muscle strength -Smoking cessation -Limits on alcohol intake -Daily foot care. Complementary and alternative therapies include acupuncture, biofeedback, transcutaneous electrical nerve stimulation (TENS), and massage.

Table 11-8 Nursing Assessments Before, During, and After a Seizure

What was the client's LOC? If consciousness was lost, at what point? Indicates area of brain involved and type of seizure. What was the client doing just before the attack? May suggest precipitating factors. In what part of the body did the seizure start? May indicate the site of seizure activity in the brain tissue; for example, if jerking movements were first observed in the right hand, the seizure focus may be in the left motor cortex. Was there an epileptic cry? Usually indicates the tonic stage of a generalized tonic-clonic seizure. Were any automatisms observed, such as eyelid fluttering, chewing, lip smacking, or swallowing? Often seen in complex, partial, and absence seizures. How long did movements last? Did the location or character change (tonic to clonic)? Did movements involve both sides of the body or just one side? Indicates areas in which focal activity originated. Did the head and/or eyes turn to one side? If so, which side? Helps localize the focus of the seizure; during the seizure, the head and eyes typically turn away from the side of the epileptogenic focus. Were there changes in pupillary reactions? Indicates involvement of the autonomic nervous system. If the client fell, was the head hit? Skull x-ray studies may be needed to rule out subdural hematoma or fracture. Was there foaming or frothing from the mouth? Usually indicates a tonic-clonic seizure.

Allocation of Resources

For at least the past two decades, the escalating cost of health care in the United States has been a concern. Gaining control over increasing healthcare expenditures has been a goal of both the government and private entities. Many factors are responsible for the increasing cost of health care. These include increased longevity, increases in the prevalence of chronic diseases such as diabetes, continued medical advances (which may result in more accurate diagnoses and better treatment, but are often more expensive than existing methods), technological advances, consumer demand, and defensive medicine. Inappropriate healthcare treatment choices by consumers have also contributed to increased healthcare costs. As discussed in the module on Managing Care, employees have enjoyed the benefits of employer-negotiated insurance plans but, as clients, have been insulated from and are often unaware of the cost of care, resulting in uninformed deci- sions about the type and amount of health care needed. Mass advertising by pharmaceutical manufacturers and specialty treatment centers directed at consumers have also contributed to inappropriate treatment choices being made by the public. As healthcare expenditures have increased, the need for resource allocation, that is, distribution of resources among competing groups of people or programs, has been recognized. When resources are being allocated, three levels of decision making must be considered: Level 1: allocating resources to health care versus other social needs Level 2: allocating resources within the healthcare sector Level 3: allocating resources among individual clients (AHC) Examples of Resource Allocation Rationing is one means of allocating healthcare resources. Rationing is a method used by individuals, insurance companies, and the government to prevent increases in the cost of health care or to reduce the cost of health care. Individuals ration when they decide to provide self-care for an illness or injury rather than seeking care from a healthcare provider. Methods used by insurance companies to ration healthcare resources include limiting the number of healthcare providers that clients can choose and denial of coverage for services (e.g., services deemed to be experimental or those that are not supported by scientific evidence that prove their efficacy). The government also rations healthcare resources, such as inclusion of the coverage gap in Medicare Plan D (known as the "donut hole") that sometimes forces beneficiaries to purchase fewer prescriptions. The Organ Procurement and Transplantation Network One of the best-known systems of allocating certain healthcare resources is the Organ Procurement and Transplantation Network (OPTN). In the United States, approximately 79 people receive a donated organ each day. Unfortunately, another 18 people die each day waiting for an organ transplant. There simply are not enough donated organs to meet the demand for transplants. The OPTN, a contracted service of the USDHHS, maintains the only national client waiting list for organ transplantation. Multiple factors determine who receives a donor organ. A few of the factors are blood and tissue type, medical urgency, organ size, time on the waiting list, and the geographic distance between the donor and the recipient. H1N1 Vaccine Distribution During 2009, there was an outbreak of H1N1 influenza. Initially an inadequate supply of vaccine was available, but as H1N1 began to spread, the Centers for Disease Control and Prevention (CDC) realized that guidelines had to be developed and implemented to ensure that the most vulnerable individuals had first access to the vaccine. As more vaccine became available, the CDC controlled its distribution by considering factors such as the amount of vaccine being requested by local health departments, the speed at which the vaccine was becoming available, and the need to ensure availability for not only the community but also active duty military personnel. Once the vaccine arrived in local communities, further decisions were made about who could receive it if the supply was insufficient to meet the demand. Many local health departments screened potential recipients and initially administered the vaccine only to individuals with risk factors for H1N1, such as small children and adults with diagnosed respiratory disease. Later, when sufficient quantities of the vaccine became available, healthcare providers were able to administer the vaccine to anyone who asked for it. Nurses and Allocation of Resources The role of the nurse in the allocation of resources is a collaborative one. Nurses are the largest group of health professionals, and as part of the interdisciplinary healthcare team, the nurse participates in allocating healthcare resources. Thus, nurses develop a significant understanding of how appropriate allocation and misallocation of healthcare resources can affect client needs and outcomes. Nurses must be aware of and participate in discussions that affect the allocation of healthcare resources in the workplace, in their communities, and at the federal level. Nurses are uniquely placed to advocate on behalf of clients when allocation of resources is being considered in their communities. They may advocate by talking with local legislators, writing to politicians, and engaging in discussions in their neighborhoods and social groups. As working professionals, nurses have the opportunity to participate in national discus- sions about resources through a number of professional organizations, such as the American Nurses Association.

CP Pharmacological Therapy

Medications are given to control seizures, to control spasms (skeletal muscle relaxants, baclofen, and benzodiazepines), and to minimize gastrointestinal side effects (cimetidine or ranitidine). Baclofen is administered by intrathecal pump to decrease muscle tone and vasospasms when oral administration is ineffective or causes side effects. Botulinum toxin injection into specific muscles is a relatively new therapy used to help control spasticity

Quantitative vs Qualitative Research

Quantitative research uses precise measurement to collect data and to analyze it statistically for a summary and a description of the resulting findings, or to test relationships among variables. An example of a quantitative question is "Are there differences in skin breakdown between premature infants who are bathed with plain water and those who are bathed with bacteriostatic soap?" Qualitative research investigates a question through narrative data that explores the subjective experiences of human beings and can provide nursing with a better understanding of the client's perspective. An example of a qualitative question is "What is the nature of coping and adjustment after a radical mastectomy?"

CP Clinical Manifestations

Cerebral palsy is characterized by abnormal muscle tone and lack of coordination, with spasticity found in the majority of cases. Children have a variety of symptoms depending on their age. Symptoms vary depending on the area of the brain involved and the degree of insult. Children with CP usually are delayed in meeting developmental milestones. For example, at 6 months of age, they may have persistent back arching, show little spontaneous movement, and be unable to sit up. They frequently have other problems, including visual defects such as strabismus (abnormal alignment of the eyes or "crossed eyes"), nystagmus (involuntary rapid eye movement), or refractory errors; hearing loss; language delay; speech impediment; or seizures. Feeding may be difficult because of oral motor involvement. Approximately 40% of children with CP also have some form of intellectual disability. Clinical Characteristics Hypotonia - Floppiness, increased range of motion of joints, diminished reflex response Hypertonia - Tense, tight muscles >Rigidity;Spasticity - Uncoordinated, awkward, stiff movements; scissoring or crossing of the legs; exaggerated reflex reactions Athetosis - Constant involuntary writhing motions that are more severe distally Ataxia - Poor muscle control during voluntary movement, poor balance Hemiplegia - Involvement of one side of the body, with the upper extremities being more dysfunctional than the lower extremities Diplegia - Involvement of all extremities, but the lower extremities are more affected than the upper, usually spastic Quadriplegia - Involvement of all extremities with the arms in flexion and legs in extension

CP Non-Pharmacologic Therapy

Clinical therapy focuses on helping the child develop to a maximum level of independence. Referrals are made for physical, occupational, and speech therapy, as well as special education to improve motor function and ability. Braces and splints, serial casting, and positioning devices (prone wedges, standers, and side-lyers) are used to promote range of motion, skeletal alignment, stability, and control of involuntary movements. They are also used to prevent contractures. Physical therapy and occupational therapy promote optimal independent functioning. Early Intervention Programs The prognosis for infants and children with CP depends on the level of physical involvement and on the presence of intellectual, visual, or hearing deficits. Early intervention programs can significantly improve performance. Many children with hemiplegia or ataxia show some improvement with maturation and are able to ambulate. Others need assistance with mobility and activities of daily living. They are usually cared for in their homes, although some receive care in long-term care facilities.

ASD Diagnostic Tests

Diagnosis is based on the presence of specific criteria, as described in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). Additional testing is done to rule out other causes of the child's behavior. Tests may include neuroimaging (com- puted tomography [CT] scan or MRI), lead screening, DNA analysis, and electroencephalography

CP Diagnostic Tests

Diagnosis is usually based on clinical findings. CP is difficult to diagnose in the early months of life, because it must be distinguished from other neurological conditions and signs may be subtle. Suspicious findings include an infant who is small for his or her age or has a history of prematurity; low birth weight; low Apgar score (0-3 at 5 minutes); or the occurrence of an inflammatory, traumatic, or anoxic event. However, the majority of children who develop CP have normal Apgar scores at birth. Ultrasonography can be used to detect fetal and neonatal abnormalities of the brain, such as intraventricular hemorrhage. Neuromotor tests are used to evaluate the presence of normal movement patterns and absence of primitive reflexes and abnormal tone. Once CP is suspected, CT scans, MRI, and positron emission tomography may be performed.

ADHD Nursing Process

Especially when caring for pediatric clients, parents and caregivers are integral to each phase of the nursing process. In particular, because collection of assessment data depends largely on client interviews, the nurse should establish effective communication patterns with the parents and caregivers Assessment The nurse often encounters the family who is concerned about the child's behavior before a diagnosis has been made. Ask about family and birth history and have the parents describe the child's behaviors. Perform developmental testing and look specifically for attention span and physical activity. Refer the family to their pediatric healthcare home for further assessment, then to a mental healthcare specialist who is experienced in diagnosing ADHD. The nurse may encounter the child with ADHD in the hospital when parents bring the child for treatment of an injury (e.g., fracture) or another problem. Explore in detail the parents' report of the child's attention span. Usually within a few minutes in an unstructured setting or waiting area, the child with ADHD becomes restless and searches for distraction. Gather information about the child's activity level and impulsiveness. Find out how the family manages at home and what treatments are being applied. Diagnosis Examples of nursing diagnoses that may be appropriate for a child with ADHD include the following: -Risk for Injury -Impaired Verbal Communication -Impaired Social Interaction -Chronic Low Self-Esteem -Risk for Caregiver -Role Strain Planning Prevention can focus on discouraging regular television exposure for young children ages 1-3 years and encouraging daily vigorous physical activity for all children. The nursing care of the hospitalized child with ADHD focuses on administering medications, managing the child's environment, implementing behavioral management plans, providing emotional support to the child and family, promoting self-esteem, and ensuring ongoing care. Care in the community includes using the same components along with guiding parents to appropriate resources when needed. Implementation Children with ADHD present a number of challenges to their parents and teachers. The nurse may need to provide client teaching to both parents and teachers regarding medications and their side effects, the importance of decreasing stimuli and minimizing distractions, and the need for consistency and patience with behavior management plans. Some trial and error may be necessary before the child's treatment team (including parents and teachers) finds the combination of therapies that is most effective for the child. Administer Pharmacologic Treatments Stimulant and nonstimulant medications increase the child's attention span and decrease distractibility. Interventions related to pharmacologic treatment include the following: -Teach parents to be alert for the common side effects of these medications, including anorexia, insomnia, and tachycardia. -Administer medication early in the day to help alleviate insomnia. Anorexia can be managed by giving medication at mealtimes. -Perform careful periodic monitoring of weight, height, and blood pressure. -Instruct families about the abuse potential of stimulant drugs; they should be locked up and administered only as directed. Minimize Environmental Distractions Children with ADHD benefit from fewer environmental distractions: -Keep potentially harmful equipment out of reach. -Limit and monitor "screen" time. -Provide a quiet, clutter-free area for study time. -Use shades to darken the room during naps or at bedtime and minimize noise. -Teach parents to minimize distractions at home during periods when the child needs to concentrate (e.g., when doing schoolwork). -When the child is hospitalized, minimizing environmental distractions may mean placement in a room with only one other child Implement Behavioral Management Plans Behavior modification programs can help reduce specific impulsive behaviors. An example is setting up a reward program for the child who has taken medication as ordered or completed a homework assignment. Depending on the child's age, the rewards may be daily as well as weekly or monthly. For example, one completed homework assignment might be rewarded with 30 minutes of basketball or a bike ride, and assignments completed for a week might be rewarded with participation in an activity of the child's choice on the weekend. If punishment is necessary, the behavior should be corrected while simultaneously supporting the child as an individual. Punishment is generally withdrawal of a privilege and should follow the offense quickly, as the child may not otherwise connect the punishment with the behavior. Provide Emotional Support Children with ADHD offer a special challenge to parents, teachers, and healthcare providers. Family support is essential. Educate both the parents and the child about the importance of appropriate expectations and consequences of behaviors. Teach skills that will help as the child grows older: making lists of tasks to accomplish; following routines for eating, sleeping, recreation, and schoolwork; minimizing stimuli in the environment when completing work; and asking teachers and friends to identify when behavior is inappropriate. When the child is hospitalized for another condition, the time may provide a brief respite from constant care by the parent. The activity, impulsivity, and general high energy of children with ADHD can fatigue parents. When the child is hospitalized, parents may want to spend a few hours each day at home or at a nearby residence for families. Ask them how they manage at home and offer ideas for respite care. Promote Self-Esteem Children with ADHD are easily frustrated, in part by their own behaviors and in part by the reactions of others. This frustration easily leads to loss of self-esteem. Nurses help children with ADHD understand the disorder at a developmentally appropriate level, and also facilitate a trusting relationship with health- care providers. Children with ADHD who build healthy relationships with healthcare providers are more likely to seek help as they grow into adulthood. Interventions to promote self- esteem may include: -Assist the child with social skills through the use of role playing, small group play, and modeling. -Promote the child's self-esteem by emphasizing the positive aspects of behavior and treating instances of negative behavior as learning opportunities. -Help the child to develop ego strengths (the conscious ability to screen outside stimuli and to control internal demands), which will result in better impulse control and thus increase the child's self-esteem over time. -Encourage skills at which the child excels and consider the use of support groups for children in school. -Praise the hospitalized child for lying still for a procedure, taking a medication on time, or helping a staff member carry toys around to other children Educate Families Parents need support to understand the diagnosis and to learn how to manage the child. Explain what the diagnosis is and what is known about attention deficit disorders. Provide written materials, Internet sites, and an opportunity to ask questions. Emphasize the importance of a stable environment at home as well as at school. At home, the child may have difficulty staying on task. Parents need to consider the child's age and developmental appropriateness of tasks, give clear and simple instructions, and provide frequent reminders to ensure completion. Routines in the evening can promote good sleep patterns. The nurse can serve as a liaison to teachers and school personnel or as the case manager for the child. An individualized education plan (IEP) may be needed, with clear expected outcomes stated for the child's behaviors. IEPs or periods of instruction free from the distractions of the entire class may enable the child to improve school performance. Parents may have difficulty understanding the need for these approaches because the child often tests at above-average intelligence. Reinforce the importance of providing a structured environment free from unnecessary external stimuli. Make sure that parents understand behavioral approaches that will help the child, the administration of prescribed medications, and the importance of returning for healthcare visits to monitor for side effects. Medication should be safely locked away at home to keep it away from other children and to prevent illegal use of the controlled substance. Parents may have heard about ADHD in the media and may have questions about its cause and management. Providing information about complementary and alternative treatments is a nursing role. The National Institutes of Health sponsors the National Center for Complementary and Alternative Medicine (NCCAM), which is a reliable source for parents and professionals. As the child grows older, provide explanations about the disorder and information about techniques that will assist in dealing with problems. Emphasize the importance of doing homework or other tasks requiring concentration in a quiet environment without background noise from a television or radio. Encourage children with ADHD to keep assignment notebooks and use checklists to help them accomplish specific tasks.

Hearing Impairment Pharmacologic Therapy

For hearing loss that is caused by upper respiratory infections or seasonal allergies, decongestants may be helpful. Sudden sensorineural hearing loss may initially be treated with steroids. For cases of otitis media, antibiotics may be prescribed. There are currently no medications available to treat permanent hearing loss. Decongestants Drug example: pseudoephedrine Enhance norepinephrine and epinephrine activity by stimulating alpha-adrenergic receptors. This causes vasoconstriction and reduces inflammation. Use with caution in clients with hyperthyroidism, hypertension, or heart disease. Instruct client to limit caffeine use because it can lead to hypertension and tachycardia. Corticosteroids Drug examples: prednisone, methylprednisolone Mimic hormones produced by the adrenal gland. Reduces inflammation and the immune response system. Warn client that grapefruit or grapefruit juice may alter the drug's uptake. Barbiturates may decrease effectiveness. Live vaccines should be avoided while taking corticosteroids. Antibiotics Drug examples: cephalosporins, penicillins, macrolides, aminoglycosides, tetracyclines, fluoroquinolones, sulfonamides Used to treat bacterial infection. Choice of antibiotic is based on bacteria causing infection. Teach importance of finishing full course of antibiotics. Observe for signs of allergic reactions. Encourage adequate fluid intake. Monitor renal and/or hepatic function if long-term use. Monitor for ototoxicity. Warn clients taking macrolides that grapefruit or grapefruit juice may alter the drug's uptake.

ASD Pharmacologic Therapy

For some clients, medications are used to manage manifestations and associated symptoms. Medications used in the care of clients with ASD may include stimulants, selective serotonin reuptake inhibitors (SSRIs), and mood stabilizers. The overall prognosis for children with ASD to become functioning members of society is guarded. The extent to which adequate adjustment is achieved varies greatly. Successful adjustment is more likely for children with higher IQs, adequate speech, and access to specialized programs.

CP Risk Factors

Increased risk for CP is found in mothers older than 40 or younger than 20 years of age, fathers who are 20 years of age or younger, and mothers or fathers with African American ethnicity. The risk is highest in first-born children and in children born subsequent to the fourth child. Prematurity, multiple births, low birth weight, blood type incompatibility, neonatal sepsis, and hyperbilirubinemia place the infant at higher risk for development of CP. Multiple risk factors at the same time can further increase the odds of developing CP. Certain maternal medical problems, such as seizure disorders and thyroid conditions, may slightly increase a child's risk for CP. Children conceived by way of assisted reproductive technology (ART) and through infertility treatments are also at a greater risk for this disorder. Maternal viral infection during pregnancy (e.g., cytomegalovirus, rubella, and chicken pox) is also associated with an increased incidence of CP

Local Health Departments

Local health departments oversee a variety of health policies and the respective regulations. For example, they are responsible for disease monitoring and surveillance in their communities. Associated activities include reporting incidents of disease to state and federal authorities as well as implementing disease prevention efforts, such as offering immunizations. Local departments of health typically oversee childcare center sanitation and food safety. They also offer a variety of community-wide disease and injury prevention programs implemented as a result of federal efforts or designed in response to local issues. Typical programs include injury prevention campaigns; lead poisoning prevention efforts; and making safety equipment such as smoke detectors, children's bicycle helmets, and infant car seats available to families at no cost. Local departments of health usually administer the Women, Infants, and Children (WIC) supplemental nutrition program, which provides food assistance to pregnant women and children under age 5 who are at risk for malnutrition.

Reducing Medication Error

Medication errors injure approximately 1.3 million people annually in the United States, with an average of at least one death every day. The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer." Medication errors usually result from multiple causes, including poor communication; ambiguities in product names, directions for use, medical abbreviations, or writing; poor procedures or techniques; and poor client understanding. Job stress, lack of product knowledge or training, and similar labeling or packaging may also contribute to medication error. Several national- and facility-implemented interventions have been designed to decrease medication errors, including bar coding both clients and medications, regulating similar names of drugs that may cause confusion, and using a computerized physician order entry system.

CP Nursing Process

Nursing care focuses on early intervention, prevention of complications, and support of children and families to help them cope with the diagnosis of CP. Assessment Be alert for children whose histories indicate an increased risk for CP. It is not uncommon for children who are delayed in meeting developmental milestones or have neuromuscular abnormalities at 1 year of age to show gradual improvement in function. Studies have shown that of the risk factors, assessment of general movements has a high predictive validity of CP among infants less than a year old. Assess all children at each healthcare visit for developmental delays. Note any orthopedic, visual, auditory, or intellectual deficits. Assess for newborn reflexes, which may persist beyond the normal age in a child with CP. Identify infants who appear to have abnormal muscle tone or abnormal posture (child has an arched back, child becomes stiff when moving against gravity, child's neck or extremities have increased or decreased resistance to passive movement). A child with asymmetric or abnormal crawling using two or three extremities indicates a motor problem. Hand dominance before the preschool years is another sign of a motor problem. Record dietary intake as well as height and weight percentiles for children suspected to have or to be diagnosed with the condition. Evaluate all infants who show symptoms of developmental delays, feeding difficulties caused by poor sucking, or abnormalities of muscle tone. Two simple screening assessments are helpful: -Place a clean diaper on the 6- to 12-month-old infant's face. The infant without special needs will use two hands to remove it, but the infant with CP will use one hand or will not remove the cloth at all. -Turn the infant's head to one side. A persistent asymmetric tonic neck reflex (beyond 6 months of age) indicates a pathological condition. Suspect CP in any infant who has persistent primitive reflexes. Diagnosis Nursing diagnoses appropriate for inclusion in the care of the child with CP vary depending on the type of CP, the particular child's symptoms and age, and the family situation. Examples of nursing diagnoses relevant to caring for the client with CP may include the following: -Risk for Injury -Impaired Mobility -Risk for Constipation -Impaired Tissue Integrity -Impaired Verbal Communication -Impaired Home Maintenance -Chronic Pain -Delayed Growth and Development -Caregiver Role Strain. Planning Because the condition can range from mild to severe and may involve numerous manifestations, care planning must be highly individualized on the basis of the specific needs of each individual. It may include the following goals: -The client will remain free from injury. -The client will demonstrate appropriate growth and development. -The client will maintain an appropriate diet to meet nutritional needs. -The client and family will monitor bony prominences to avoid altered skin integrity. Implementation Interventions need to be adapted to the particular child and family. Nursing care focuses on providing adequate nutrition, maintaining skin integrity, promoting physical mobility, promoting safety, promoting growth and development, teaching parents how to care for the child, and providing emotional support. Prevent Injury Clients with CP have varying degrees of mobility. The nurse should ensure that the client receives the degree of assistance required for safe ambulation, and that orthotic and assistive devices are properly used. Maintaining a safe environment includes eliminating all potential obstacles from walkways and providing adequate lighting. Assess caregivers and family members for awareness of safety precautions and provide teaching as needed. Safety belts should be used for children in strollers and wheelchairs. An adaptive car safety seat may be needed to transport the child safely. A child with chronic seizures should wear a helmet to protect against further injury. Provide Adequate Nutrition Children with CP require high-calorie diets or supplements to the diet because of feeding difficulties associated with spasticity. Many children have difficulty chewing and swallowing. Give the child small amounts of soft foods at a time. Utensils with large, padded handles may be easier for the child to use. Maintain Skin Integrity Take special care to protect the bony prominences from skin breakdown. Monitor the skin under splints and braces for redness. If the skin is red, the braces or splints should be removed and not replaced until the redness is gone. Proper body alignment should be maintained at all times. Support the child with pillows, towels, and bolsters whether the child is in bed or in a chair. Support the head and body of a floppy infant. A child with spasticity may have scissored, extended legs, and a child with athetoid movements may be difficult to carry and transport. Promote Physical Mobility Range-of-motion exercises are essential to maintain joint flexibility and to prevent contractures. Consult with the child's physical therapist and help with recommended exercises. Teach parents to position the child to foster flexion rather than extension so that the child can more easily interact with the environment (for example, by bringing objects closer to the face). Consider the use of therapeutic massage or relaxation training to manage pain associated with spasticity and stretching exercises. Adaptive and assistive technology may be needed to promote mobility and communication. Assistive technology is any item, equipment, or product customized for use to promote the functional capabilities and independence of an individual with disabilities. Examples include computers, adaptive utensils, and customized wheelchairs. Refer parents to the appropriate resources for help obtaining adaptive devices. Encourage par- ents to bring in the child's adaptive appliances (braces, positioning devices) for use during hospitalization. Promote Growth and Development Remember that many children with CP have physical disabilities but not necessarily intellectual disabilities. Use terminology appropriate for the child's developmental level. Help the child develop a positive self-image to ensure emotional health and social growth. Adaptive devices may be available to help the child with CP to communicate more independently. Children with a hearing impairment may need a referral to learn American Sign Language or other communication methods. Provide audio and visual activities for the child who is quadriplegic. Foster Parental Knowledge Teach parents about the disorder and arrange sessions to teach them about all of the child's special needs. Teach administration, desired effects, and side effects of medications prescribed for seizures. Make sure parents are aware of the need for dental care for children taking anticonvulsants and other medications, because they can impact oral health. Parents also may need suggestions for amending parenting strategies to promote the child's autonomy and abilities. Provide Emotional Support Parents require emotional support to help them cope with the diagnosis. Listen to the parents' concerns and encourage them to express their feelings and ask questions. Explain what they can expect from future treatment. Refer parents to individual and family counseling if appropriate. Work with other healthcare professionals to help families adjust to this chronic disease

Occupational Safety and Health Administration

OSHA works to ensure the health and safety of Americans in the workplace. Most employees in the nation fall under OSHA's jurisdiction. Part of OSHA's mission is to provide assistance to employers, who are responsible for providing workers with a safe and healthful workplace and for reducing or eliminating workplace hazards. In general, OSHA sets standards requiring that employers maintain conditions or adopt practices that are reasonably necessary and appropriate to protect workers on the job; be familiar with and comply with standards applicable to their businesses; and ensure that employees have and use personal protective equipment when required for safety and health. OSHA issues standards for a wide variety of workplace hazards in industrial and healthcare settings. Two examples of OSHA standards are the availability of both personal protective equipment (PPE) and emergency eyewash stations. OSHA provides training, outreach, and education to employers and employees; establishes cooperative partnerships (for example, with employers, employees, and unions); and encourages improvement of workplace safety and health. In support of these activities, OSHA provides employers and employees information and training materials that focus on safety and health hazards in the workplace.

Know what a PICOT question is, and what the letters stand for, and how to identify each component.

PICOT is a consistent "formula" for developing answerable, researchable questions. o P= Population o I= Intervention o C= Comparison o O= Outcome o T= Timeframe · An example of a PICOT question can be the following: "Does handwashing with soap and water versus a waterless alcohol based rub (hand sanitizer) among healthcare workers reduce hospital acquired infections in fiscal year 2018?"

Case Management Critical Pathways

Successful case management relies on critical pathways to guide care. The term critical pathway, also called a care map, refers to the expected outcomes and care strategies developed through collaboration by the healthcare team. Again, the interdisciplinary team must reach consensus regarding client care and determine specific, measurable outcomes. Critical paths provide direction for managing the care of a specific client during a specified time period. Critical paths are useful because they accommodate the unique characteristics of the client and the client's condition while making use of the predictable characteristics of the course of the client's disease or injury. Critical paths use resources appropriate to the care needed, thereby reducing cost and length of stay. Critical paths are used in every setting where health care is delivered. A critical path quickly orients the nurse to the outcomes that should be achieved for the client for that day. Nursing diagnoses identify the outcomes needed. If client outcomes are not achieved, the case manager is notified and the situation is analyzed to determine how to modify the critical path. Altering time frames or interventions is categorized as a variance, and the case manager tracks all variances. After a time, the appropriate collaborative practice teams analyze the variances, note trends, and decide how to manage them. Teams may then revise the critical pathway or decide to gather additional data before making changes. Some features are included on all critical paths. These include the specific medical diagnosis, the expected length of stay, client identification data, appropriate time frames (in days, hours, minutes, or visits) for interventions, and client outcomes. Interventions are presented in modality groups (medications, nursing activity, and so on). The critical path must include a means to identify variances easily and to determine whether outcomes are met. Normally a client would be expected to be discharged on the sixth day after surgery. This path describes expectations for days 1-3. A recent evolution in critical paths is the inclusion of actual and potential nursing diagnoses with specific time frames into the critical pathway. Education paths are also excellent tools for planning client and family education. A copy of the client's education plan is given to the client and the family, and the nurse reviews the information with them. Thus, both the client and the family know what to expect during an anticipated, uncomplicated hospitalization.

CP Surgery

Surgical interventions may be required to improve function by balancing muscle power and stabilizing uncontrollable joints. The Achilles tendon may be lengthened to increase range of motion in the ankle, which allows the heel to touch the floor and thus improves ambulation. The hamstrings may be released to correct knee flexion contractures. Other procedures may be performed to improve hip adduction or correct the foot's natural position. A dorsal rhizotomy may be performed for spastic diplegia to cut the afferent fibers that contribute to spasticity; however, some muscle weakness may result from the procedure and there is evidence that it does not prevent contractures or improve functioning in the long term.

The Department of Health and Human Services

The U.S. Department of Health and Human Services (DHHS) is the federal government's principal agency for the protection of the health of all Americans and the provision of essential human services for those least able to care for themselves. The more than 300 divisions and programs within this department range from health research and the provision of health-related information by the National Institutes of Health (NIH) to healthcare financing. through the Centers for Medicare and Medicaid Services (CMS). DHHS oversees services for individuals at all stages of life through its Administration for Children and Families and its Administration on Aging. The 2013 DHHS budget is $941 billion. Components of DHHS include the Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDC), and Agency for Healthcare Research and Quality (AHRQ). DHHS is a powerful agency, as it administers more grant dollars than all other federal agencies combined and represents almost one-quarter of all federal outlays.

Peripheral Neuropathy Patho and Etiology

The peripheral nervous system (PNS) links the central nervous system (CNS) with the rest of the body. The PNS is responsible for receiving and transmitting information from and about the external environment. It consists of nerves, ganglia (groups of nerve cells), and sensory receptors located outside—or peripheral to—the brain and spinal cord. The PNS is divided into a sensory (afferent) division and a motor (efferent) division. Most nerves of the PNS contain fibers for both divisions, and all nerves are classified regionally as either spinal nerves or cranial nerves. Damage to these nerves can interrupt communication between the brain and the body, affecting normal muscle movement and sensory perception and causing pain. The main components of peripheral nerves are the axon and myelin. Peripheral neuropathy can be classified according to the predominant pathology: axonal degeneration or segmental demyelination. The peripheral neuropathies (also called somatic neuropathies) include polyneuropathies and mononeuropathies. Polyneuropathies, the most common types of neuropathy associated with diabetes, are bilateral sensory disorders. The manifestations appear first in the toes and feet and progress upward. The fingers and hands also may be involved, but usually only in later stages of diabetes. The manifestations of polyneuropathies depend on the nerve fibers involved. Mononeuropathies are isolated peripheral neuropathies that affect a single nerve. Injury or trauma is the most common cause, although repetitive motions, such as those resulting in carpal tunnel syndrome, also can cause mononeuropathies. Etiology Neuropathies are classified by one of three causes: acquired, hereditary, or idiopathic. Acquired neuropathies include those caused by disease or illness, nutritional deficits, infection, trauma, and toxins. Hereditary, or inherited, neuropathies include Charcot-Marie-Tooth disease. Idiopathic neuropathies are from an unknown cause and account for up to 30% of neuropathies. The etiology of polyneuropathy is varied; it often is caused by complications of diseases such as diabetes, exposure to toxins, and poor nutrition (in particular, vitamin B deficiency). One of the most serious polyneuropathies is Guillain-Barré syndrome (GBS), an acute inflammatory demyelinating disorder of the peripheral nervous system characterized by an acute onset of motor paralysis (usually ascending). The classification of Guillain-Barré subtypes includes acute inflammatory demyelinating polyradiculoneuropathy, acute axonal motor neuropathy, and acute motor and sensory axonal neuropathy. Guillain-Barré syndrome is one of the most common peripheral nervous system disorders, affecting approximately 3,000-6,000 people annually in the United States. The cause is unknown, but precipitating events include a respiratory or gastrointestinal viral or bacterial infection 1-3 weeks prior to the onset of manifestations, surgery, viral immunizations, and other viral illnesses. In 60% of cases, Campylobacter jejuni is identified as the cause of the preceding infection. Approximately 80%-90% of clients with GBS have a spontaneous recovery with little or no residual disabilities. The disease is characterized by progressive ascending flaccid paralysis, accompanied by paresthesias (a subjective feeling of a change in sensation, such as numbness or tingling) and numbness. About 20% of clients have respiratory involvement to the point that ventilatory assistance is required. GBS is often a medical emergency. The primary pathophysiological process in GBS is the destruction of myelin sheaths covering the axons of peripheral nerves. The demyelination is thought to be the result of both a humoral- and cell-mediated immunological response. The loss of myelin results in poor conduction of nerve impulses, causing sudden muscle weakness and loss of reflex response. Other manifestations occur when nerve conduction to various muscles is interrupted. Systemic diseases often are the cause of peripheral neuropathy. Damage from disease processes such as metabolic and endocrine disorders affects the body's ability to process waste products and utilize nutrients. Conditions that decrease oxygen supply may cause a thickening of the walls of blood vessels that supply nerves, resulting in a reduced blood flow. Between 60% and 70% percent of individuals with diabetes develop some type of neuropathy. Autoimmune disorders and infections also can cause peripheral neuropathy. Viruses and bacteria can attack nerve tissues (or cause the body to attack nerve tissues), resulting in the destruction of nerve axons or the myelin sheath. Sensory neuropathies with manifestations of numbness, tingling, and pain in the lower extremities affect about 30% of clients with AIDS. A Guillain-Barré type of inflammatory demyelinating polyneuropathy also can occur, resulting in progressive weakness and paralysis. In addition, untreated Lyme disease can cause extensive peripheral nerve damage. Other disease processes that can result in peripheral neuropathy include the following: -Alcoholic neuropathy is damage to the nerves that results from long-term excessive use of alcohol. Malnutrition is a serious complication of chronic alcoholism; thiamine (B1) deficiency that may be associated with chronicalcoholism is characterized by progressive cognitive deterioration, confabulation, myopathy, and peripheral neuropathy. -Inflammation, cancer, and toxins, including some types of chemotherapy, other medications, and environmental chemicals, such as lead, can damage nerve tissue and fibers, resulting in peripheral neuropathy. -Inflammation and swelling in tendon sheaths can lead to peripheral neuropathy. The carpal tunnel is a canal through which flexor tendons and the median nerve pass from the wrist to the hand. Carpal tunnel syndrome develops from narrowing of the tunnel and compression of the median nerve as a result of inflammation and swelling of the synovial lining of the tendon sheaths. The prognosis for clients with peripheral neuropathy ranges from the neuropathy resolving (e.g., the underlying cause is successfully treated) to cases in which the client does not respond to treatment or the cause is not identified and the condition persists indefinitely.

Alzheimer Disease Patho and Etiology

There are two basic types of AD: familial and sporadic. Familial AD (FAD) has a strong inherited component and is also called early-onset AD because it usually manifests before age 65. Sporadic AD shows no clear pattern of inheritance, although genetic factors may be involved. Because it typically develops after age 65, sporadic AD is sometimes referred to as late-onset AD, and it is more common than its early-onset counterpart, accounting for 90% or more of all cases. FAD and sporadic AD both involve the same set of pathophysiological changes. Why these changes occur and how to prevent them remain active areas of research, although some answers have begun to emerge. Individuals who suffer from AD show a pattern of degenerative changes related to neuronal death throughout the brain. The cells die in a characteristic order, beginning with neurons in the limbic system, including the hippocampus. Damage to this region results in emotional problems and loss of recent memory. From there, the destruction spreads up and out toward the cerebral surface. Eventually, neuronal death in the cerebral lobes produces a range of symptoms, including loss of remote memory. As AD progresses and more neurons die, two characteristic abnormalities develop in the brains of affected individuals. The first is thick protein clots called neurofibrillary tangles, and the second is insoluble deposits known as amyloid plaques. Beyond plaques and tangles, researchers have noted several other brain irregularities associated with AD. One such finding is elevated levels of the neuropeptide galanin, which is released by neurons as they are injured. The exact role of galanin in AD remains unclear. Some studies suggest it exerts a protective effect, increasing acetylcholine release by the remaining neurons and slowing cognitive decline. Other studies suggest that an overabundance of galanin contributes to AD symptoms by reducing memory and learning capacity. Some other abnormal findings associated with AD are a bit less mysterious. For example, CT scans of the brains of AD sufferers show reduced blood flow, enlarged ventricles, and gross cerebral atrophy, all of which are consequences of widespread neuronal death. Decreased numbers of neurons also result in low levels of several neurotransmitters, including acetylcholine, which is thought to have a negative effect on cognition. Etiology Researchers are not sure why most cases of AD arise, although a variety of genetic and environmental factors appear to be involved. Moreover, the exact biochemical origins of AD remain unknown, even in clients who clearly have an inherited form of the disease. Researchers have thus proposed several theories that seek to explain the disease process, including the cholinergic, amyloid, and tau hypotheses. CHOLINERGIC HYPOTHESIS The cholinergic hypothesis emerged in the early 1980s after nearly 20 years of investigation into the role of neurotransmitters. Researchers noted that lowered levels of acetylcholine (a cholinergic neurotransmitter) appeared to produce memory deficits. Autopsies also revealed that brains of individuals with AD had markers characteristic of decreased acetylcholine function. These findings suggested that AD was caused by below-normal production of acetylcholine in the brain. Although the cholinergic hypothesis was widely accepted at the time of its proposal, it has lost much of its support in recent years, primarily because drugs that boost acetylcholine function have had only modest therapeutic results. AMYLOID HYPOTHESIS Today, the amyloid and tau hypotheses are considered more likely explanations of the bio- chemistry of AD. The amyloid hypothesis states that AD arises when the brain cannot properly process a substance called amyloid precursor protein (APP). Incorrect processing leads to the presence of short, sticky fragments of APP known as beta-amyloid. Eventually, the fragments clump together, forming insoluble deposits called amyloid plaques. These plaques damage the surrounding neurons, killing them and provoking an inflammatory response that may result in further brain damage. TAU HYPOTHESIS The tau hypothesis focuses on a protein known as tau. Normally, tau holds together the microtubules responsible for intracellular transport within the axons of neurons. With AD, however, individuals have abnormal tau proteins that join and twist, forming neurofibrillary tangles instead of the microtubule network necessary for cellular survival. OTHER HYPOTHESES Beyond these three theories, several other mechanisms of AD have been proposed. Some researchers theorize that AD arises due to excessive myelin breakdown. (Myelin is the fatty substance that sheathes the axons of neurons and speeds message transmission.) Other scientists propose that oxidative stress—or buildup of by-products from oxidative metabolic reactions—plays a role in AD onset. Although these hypotheses are intriguing, they, too, have yet to garner definitive experimental support.

Alzheimer's Disease Pharmacologic Therapy

There is currently no cure for AD. Thus the main goal of drug therapy is to slow a client's decline to the greatest degree possible. Several categories of medication are used for this purpose, with limited success. Some clients also receive other drugs aimed at controlling related symptoms such as anxiety, depression, and psychosis. As discussed in the Pharmacologic Therapy section on pages 1591-1593, two classes of medication are prescribed specifically to slow AD progression: acetylcholinesterase inhibitors and NMDA receptor antagonists. Acetylcholinesterase inhibitors have been standard treatment for the past decade. They work by reducing acetylcholine breakdown. Because individuals with Alzheimer's disease are gradually losing neurons that communicate by using this substance, the presence of extra acetylcholine increases communication among the remaining neurons. This appears to temporarily stabilize symptoms related to language, memory, and reasoning for an average of 6-12 months. Commonly prescribed acetylcholinesterase inhibitors include donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne). Rivastigmine and galantamine are approved for early to moderate stages of AD, while donepezil is approved for all stages. Although these drugs all act similarly, not all individuals respond to them in the same way, if at all. In fact, about half of individuals who take these drugs see no delay in symptom progression. Acetylcholinesterase inhibitors generally produce few side effects. Those that do occur are usually mild and may include decreased appetite, nausea, diarrhea, headaches, and dizziness. NMDA receptor antagonists differ from acetylcholinesterase inhibitors in several ways. Instead of boosting acetylcholine levels, they block the effects of glutamate. Large amounts of this neurotransmitter are released when neurons are damaged by AD, and it appears they contribute to further brain deterioration. Thus NMDA receptor antagonists do not remedy existing damage, but they do slow the rate at which new damage occurs. Also unlike acetylcholinesterase inhibitors, NMDA receptor antagonists generally are not prescribed until an individual is in the moderate to severe stages of AD. In some cases, they may be given in conjunction with acetylcholinesterase inhibitors. Currently, memantine (Namenda) is the only NMDA receptor antagonist approved by the U.S. Food and Drug Administration (FDA). Its side effects are less common and usually less severe than those associated with donepezil, rivastigmine, and galantamine. They include dizziness, constipation, confusion, headache, fatigue, and increased blood pressure. Researchers continue to investigate other medications that may have a protective effect against AD. Some studies suggest that several classes of antihypertensive drugs—including angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers—may be useful, although the results of these studies are far from conclusive. Because there are so few drugs aimed at AD, practitioners often rely on other medications to address clients' symptoms, such as atypical antipsychotics (to treat delusions or hallucinations), anxiolytics (to treat anxiety), and SSRI antidepressants (to treat depression).

Lifespan Considerations Glaucoma in Children

-Surgery to reduce intraocular pressure is the treatment of choice because medications used to combat glaucoma in adults are not as effective in children. -Treatment is not always successful, especially if the child has congenital glaucoma. So parents' feelings regarding care of a child with a visual disability should be explored. -If treatment is not successful, the nurse should refer the family to resources for families with children with visual impairments and, when appropriate, for counseling. School-age children are eligible for services from the public school system. Young children may receive early intervention services through agencies such as preschool developmental day centers. -Approximately 80%-90% of infants who receive prompt diagnosis and treatment will do well and have normal or near-normal vision throughout their lifetime. -Primary congenital glaucoma will result in blindness for 12%-15% of clients. Those that do not receive prompt diagnosis and treatment will have more visual damage.

Peripheral Neuropathy Nursing Process

Application of the nursing process to care of the client with known or suspected peripheral neuropathy requires significant collaboration with the client. Because the assessment interview may reveal aspects of the client's condition that are not made evident through physical assessment, it is essential for the nurse to establish effective communication with the client. Assessment A health assessment to determine problems with the peripheral nervous system may be conducted during a health screening, may focus on a chief complaint (such as tingling), or may be part of a total health assessment. Analyze onset, characteristics, course, severity, precipitating and relieving factors, and any associated symptoms, noting the time and circumstances. For example, ask the client the following questions: -Describe the location and intensity of the pain you have been experiencing in your left leg. Is it made worse by coughing, sneezing, or walking? -When did you first notice that you were having numbness in your fingers? Questions about present health status include information about numbness, tingling sensations, tremors, problems with coordination or balance, and loss of movement in any part of the body. Carefully assess older adults for impaired balance and fall risk. Ask the client about difficulty with other senses, including detecting odors. In addition, assess for mood and anxiety, changes in sleep patterns, and ability to perform self-care and activities of daily living, sexual activity, and weight. Inquire about use of medications, including over-the-counter products and herbal supplements. Ask about past history of seizures; fainting; dizziness; headaches; infection and any trauma; tumors; and surgery of the brain, spinal cord, or nerves. Discuss illnesses that may cause neurological manifestations, including cardiac disease, strokes, pernicious anemia, sinus infections, liver disease, and/or renal failure. Also ask the client about family history of neurological health problems, diabetes mellitus, hypertension, seizures, or mental health problems. Question the client about occupational hazards, such as exposure to toxic chemicals or materials, and the amount of time spent performing repetitive motions (e.g., data entry and assembly). Information about the client's diet, use of tobacco, alcohol, or drugs, and use of safety and protective equipment also may be helpful. A physical exam should include cranial nerve and sensory/motor assessments. Diagnosis Nursing diagnoses for the client with peripheral neuropathy will differ based on the type of neuropathy and comorbidities. They may include the following: -Risk for Injury -Ineffective Peripheral Tissue Perfusion -Pain -Anxiety Planning Identified outcomes relevant to the plan of care for the client with peripheral neuropathy may include the following: -The client will remain free from injury. -The client will report effective pain management through use of a predetermined pain rating scale. -The client will verbalize feelings and concerns related to sensory loss. Implementation Nursing care is focused on promoting client safety and comfort. While the nursing plan of care is tailored to meet the needs of each individual client, general interventions relevant to the plan of care for the client with peripheral neuropathy target injury prevention and comfort promotion in both the physiological and psychosocial realms. Prevent Injury Ensure client safety. Those with compromised feeling in the extremities may be unaware that they have sustained injury. -Teach clients and their families preventive and comfort measures. Clients with GBS may require frequent teaching if anxiety interferes with ability to understand. When possible, include the client and family in decision making; for example, seek their input when planning a daily schedule of care that incorporates various therapies. Teaching topics, depending on the type of peripheral neuropathy and the extent of nerve damage, may include: >Foot care, as the client may not feel injuries to the feet—especially important for clients with diabetes >Exercise >Smoking cessation >Avoidance of toxic chemicals >Nutrition, stressing its importance and identifying sources of B12 >Avoidance of repetitive motion and/or prolonged pressure >Massage to improve circulation, stimulate nerves, and reduce pain >Referrals as appropriate. Promote Comfort Pain experienced with peripheral neuropathy varies. Pain and tenderness in muscles can be severe; interventions must be individualized to client needs. The intense pain combined with altered sensations leads to anxiety. Nursing interventions can make a difference in breaking the cycle of increasing pain that leads to increased anxiety, which can cause more pain. -Listen to the description of pain; determine presence of triggers or a pattern. Acknowledging the client's perception of pain is a basis for treatment; listening establishes trust. -Use a pain scale for determining extent of pain. Consistent measurement is essential to evaluate degree of pain and effectiveness of intervention. -Use the following complementary therapies to help manage pain: >Application of heat/cold >Guided imagery >Relaxation techniques >Massage. Presenting options for managing pain gives the client control over the situation and helps reduce anxiety. Noninvasive interventions may augment the therapeutic benefit of medications. -Provide analgesics as indicated; administer on a regular schedule rather than waiting until pain becomes severe. Anticipating and managing pain before it becomes severe decreases anxiety and averts the cycle of increased anxiety leading to increased pain. -For clients with GBS, monitor for side effects of analgesics, particularly respiratory depression; assess respirations and lung sounds. Perform routine pulmonary care measures and monitor for aspiration. Frequent respiratory monitoring is indicated.

Glaucoma Diagnostic Tests

-Tonometry indirectly measures intraocular pressure. Contact or noncontact tonometry may be used. Routine tonometry screening is recommended for everyone over the age of 60. A single elevated pressure reading does not warrant a diagnosis of glaucoma; variations in intraocular pressure occur throughout the day. -Funduscopy (visual inspection of the optic fundus using an ophthalmoscope) identifies pallor and an increase in the size and depth of the optic cup on the optic disc. These changes are significant for a diagnosis of glaucoma. -Gonioscopy uses a gonioscope to measure the depth of the anterior chamber. This test differentiates open-angle from angle-closure glaucoma. -Visual field testing identifies the degree of central visual field narrowing and peripheral vision loss. The client with glaucoma may retain 20/20 central vision even when there is severe peripheral vision loss.

Peripheral Neuropathy Prevention

Controlling medical conditions that increase risk for peripheral neuropathy is one of the best prevention methods. A healthy diet of vegetables, fruits, and whole grains can help improve nerve health. Intake of vitamin B12 can be helpful as well. Avoiding triggers that contribute to nerve damage, such as repetitive motions, smoking, toxic chemicals, and cramped positions, will also help in prevention of neuropathies.

ADHD Prevention

At this time, there is no known way to prevent the development of ADHD. Clients should avoid smoking, drugs, and alcohol during pregnancy to help prevent behaviors that are similar to ADHD. Learning good parenting skills and having consistent behavior rules, as well as teaching attention skills through reading and puzzles rather than television, can help children with or without ADHD.

Seizure Nursing Process

Assessment After the client's first seizure, a thorough history must be taken from the parent, primary caretaker, or witnesses to the event. A description of the seizure and its length should be noted, in addition to whether an aura was present and whether the client lost consciousness. This information helps to identify the type of seizure according to the International Classification of Epileptic Seizures. Perform a complete physical and neurological examination. Assess and monitor the client's physiological status. Observe the specific seizure activity, LOC, vital signs, and signs of hypoxia. During the postictal period, monitor vital signs, perform neurological checks, and ensure safety. Once the client is stable, a more definitive assessment can be made. LOC is one of the most important indicators of neurological function. Remember that a lack of response may be the result of the postictal state. To help determine the type of seizure, collect and analyze historical information about the seizure activity, clustering, the aura, the motor activity or changes in muscle tone, automatisms, and any changes in developmental performance. Assess the family's adaptation to the seizure disorder, including how well the family is coping with the uncertainty of when the next seizure will occur. Diagnosis Common nursing diagnoses for an individual with a seizure disorder include the following: -Ineffective Breathing Pattern -Ineffective Airway Clearance -Risk for Trauma -Chronic Low Self-Esteem -Anxiety -Ineffective Therapeutic Regimen Management -Readiness for Enhanced Family Processes Planning Nursing care focuses on maintaining airway patency, ensuring safety, administering medications, and providing emotional support. Both acute care and long-term management are involved. Planning also may include developing a seizure action plan for the client, particularly for children, so that family, close friends, teachers, and other caregivers or even professional colleagues know how to respond appropriately in the event the client has a seizure. Implementation Nursing interventions during seizures include the following: -Place nothing in the client's mouth during a seizure; loose teeth may be knocked out and aspirated. Position the client on his or her side so secretions can drain. Monitor to ensure adequate oxygenation: Mucous membranes should be pink, the heart rate should be at a normal or slightly elevated rate for age, and the pulse oximetry reading should be greater than 95%. Oxygen is usually administered when the pulse oximetry reading (SpO2) falls below 95%. -Protect the client from self-harm during violent seizures. If the client is in bed, the side rails should be padded to prevent injury. Children who have frequent, recurrent seizures should wear helmets to protect their heads during falls. All clients with seizure disorders should wear some form of medical alert identification. Maintain functioning suction at the bedside to clear the airway as necessary. -Take special precautions when administering intravenous medications (diazepam, lorazepam, or phenytoin) for the emergency management of status epilepticus. Give these medications very slowly over several minutes to minimize the risk of respiratory or circulatory collapse. -Give medications for the ongoing management of seizuresorally. Crushing pills and mixing them in a teaspoonful of applesauce, pudding, or other soft food make them more palatable and easier for a child or older adult to swallow if the pill is one that may be crushed. -Understand that the loss of control of body movements and possible loss of consciousness make seizures frightening and difficult to accept. Parents often feel guilty about a child's seizure disorder and compensate by not disciplining or restricting the child appropriately. Stress the need to treat the child as normally as possible. Refer the child and family to support groups and counseling services if indicated. -Encourage clients and their families to express their fears and anxieties. Answer questions honestly and refer to organizations such as the Epilepsy Foundation of America, where clients and family can get more information about the disorder. Make sure parents know how to administer medications and keep their child safe.

Hearing Impairment Non-pharmacologic Therapy

If hearing loss in a client is permanent, a multidisciplinary team is formed to assist the client and family with adaptation to the disability. Team members may include any of the following: physician, nurse, a speech/language, occupational, or physical therapist, audiologist, teacher, social worker, and family members and caregivers. The team may provide strategies and accommodations for a client whose loss is correctable until surgery is completed or other treatments take effect. Therapists and social workers can often assist clients in accessing assistive technology devices at relatively low cost, especially if they are not covered by insurance, as well as help the client learn how to use these tools. Amplification A hearing aid or other amplification device can help many clients with hearing deficits. These assistive devices do nothing to prevent, minimize, or treat the hearing loss itself. They amplify the sound presented to the hearing apparatus of the ear, which may bring the level of sound above the hearing threshold, allowing more accurate perception and interpretation of its meaning. When sound perception is distorted, a hearing aid may be less helpful, because it simply amplifies the distorted sound. Hearing aids must be individually prescribed by an audiologist. Proper design, proper fit, and regular maintenance are necessary to maintain their effectiveness. Unfortunately, less than one-fifth of older clients with a hearing deficit have or use a hearing aid. Denial of the deficit, other health problems, poor visual acuity, and decreased manual dexterity all contribute to this low usage. Cost is another factor. Health insurance plans typically cover only one pair of hearing aids within a certain time frame, and in most states Medicare does not pay for hearing aids at all. Some clients choose not to pay for hearing aids. All hearing aids include a microphone, amplifier, speaker, earpiece, and volume control. Many include an option to turn off the microphone when using the telephone; others can be adjusted for the client's pattern of hearing loss. Hearing aids are available in a variety of styles, each with advantages and disadvantages: -Canal hearing aids (in-canal and completely-in-canal) are the least noticeable style, fitting in the ear canal. They are appropriate for mild to moderately severe hearing loss. These small and unobtrusive devices allow use of the telephone and can be worn during exercise. Because of their small size, the client must have good manual dexterity to insert, clean, and change the batteries in canal hearing aids. For this reason, older clients or clients with impaired dexterity may be unable to use them. -The in-ear style of hearing aid fits into the external ear and is used for mild to severe hearing loss. Its larger size makes manipulation somewhat easier, although it still may be difficult for less dexterous individuals. A greater degree of amplification is possible with the in-ear aid. Many have a toggle switch for telephone usage. -The behind-ear hearing aid allows finer adjustment of the level of amplification and is easier for the client to manipulate. This device can be used by clients with mild to profound hearing loss. For the client who wears glasses, this style can be modified, with all components fitting into the temple of the eyeglasses. With both the in-canal and in-ear style, cleaning is important. Small portals may become plugged with cerumen, interfering with sound transmission. For the client who does not have a hearing aid, an assistive listening device, or "pocket talker," with a microphone and earpieces is useful. Pocket talkers are available over-the-counter or through an audiologist and are relatively inexpensive. The earpiece requires no special fitting, and the external microphone allows the client to focus on the desired sound rather than simply amplifying all sounds. Assistive listening devices may also be used in conjunction with a hearing aid. Clients with tinnitus may find a white or pink noise-masking device helpful to promote concentration and rest. These devices conduct a pleasant sound to the affected ear, allowing the client to block out the abnormal sound. TTD/TTY telephones and phones with amplifiers are available to assist clients who are deaf or hearing impaired in communicating with the outside world. Accessibility to the Internet can make an extraordinary difference in the quality of life to an individual with a hearing impairment, who can now make restaurant and airplane reservations by computer, as well as communicate by e-mail. Additional Therapies For uncorrectable hearing loss, several approaches are used to enhance communication. Clients with hearing impairment may receive speech therapy and instructions in lip reading, signing, cuing, and finger-spelling.

Hearing Impairment Nursing Process

In planning and implementing nursing care for the client with a hearing deficit, the type and extent of hearing loss, the client's adaptation to the loss, and the availability of assistive hearing devices are considered, as well as the client's ability and willingness to use assistive devices. Assessment Health history. Perceived ability to hear; effect of hearing loss on function and lifestyle; risk factors such as use of ototoxic medications; upper respiratory tract or frequent ear infection; noise exposure; presence of vertigo, tinnitus, unsteadiness, or imbalance. Physical examination. Apparent perception of normal speech; inspection of external ear, tympanic membrane; whisper, Rinne, and Weber tests; tests of balance and cranial nerve function. Diagnoses Possible nursing diagnoses for the client with hearing impairment may include the following: Risk for Injury Impaired Verbal Communication Social Isolation. Planning Appropriate outcomes for the client with hearing impairment are based on the extent of the deficit and may include the following: -The client will remain free from injury. -The client will wear hearing protection and have no further loss of hearing. -The client will find the best method of communication with others including sign language, hearing aids, writing, and lip reading. -The client will remain involved in his community and not experience social isolation or decreased feelings of self-worth. Implementation All hearing loss can cause safety concerns for the client and contribute to feelings of isolation and lowered self-esteem. Therefore, the goals of nursing care are to promote client safety, encourage social interaction, and promote feelings of self-worth. Promote Optimal Wellness Whether the client's hearing deficit is partial or total, impaired sound perception is the primary problem. The client needs to understand what causes the deficit and what to expect for the future. Nursing interventions focus on maximizing available hearing and preventing further deterioration to the extent possible: -Encourage the client to talk about the hearing loss and its effect on activities of daily living. Hearing loss affects each individual in a different way. The client may be denying the extent of the deficit or grieving the loss. Listening and providing support encourage the client to develop coping strategies. -Provide information about the type of hearing loss. Refer to an audiologist for evaluation of the hearing loss and possible exploration of amplification devices. With improved understanding of the deficit, the client can plan ways to compensate. -Replace batteries in hearing aids regularly and as needed. Hearing aid batteries last approximately 1 week. If a battery is old or has been improperly stored, its life may be reduced further. -Talk with the family members about techniques they can use to make communication with the client easier. The same techniques the nurse employs can be used by family members. -Check hearing aids for patency, cleaning out cerumen as necessary. Facilitate Communication A hearing deficit impairs the client's ability to receive and interpret verbal communication. A hearing loss affects the client's ability to follow conversations, use the telephone, and enjoy television or other forms of entertainment. Use the following techniques to improve communication: -Wave your hand or tap the client on the shoulder before beginning to speak. -If the client wears corrective lenses, ensure that they are clean, and encourage the client to wear them. -When speaking, face the client and keep your hands away from your face. -Keep your face in full light. -Reduce the noise in the environment before speaking. -Use a low voice pitch with normal loudness. -Use short sentences and pause at the end of each sentence. -Speak at a normal rate, and do not over articulate. -Use facial expressions or gestures. -Provide a magic slate for written communication. Individuals with hearing impairments often lip read, making good visibility of the speaker's face necessary. Excessive environmental noise interferes with the ability to perceive the message. Higher tones are typically lost with presbycusis and other types of hearing loss. Using short sentences and pausing give the client time to interpret the message. Overarticulating makes it more difficult to follow the flow and to lip read. Nonverbal cues and written messages enhance the client's understanding. Additional techniques include the following: -Do not place intravenous catheters in the dominant hand. The client may need to use that hand to write. -Rephrase sentences when the client has difficulty understanding. Hearing losses may affect different sound tones, making some words more difficult to comprehend. Using alternative words and phrases may increase the client's ability to perceive the message. -Repeat important information. The nurse must make sure that the client understands the information. -Inform other staff about the client's hearing deficit and effective strategies for communication. Consistent use of effective strategies for communication decreases the client's frustration. Encourage Socialization The client with impaired hearing often becomes socially isolated. This isolation may be self-imposed because of difficulty communicating, especially in a group. Often, however, the isolation comes about gradually and without intention. The client finds social settings such as family dinners or community gatherings increasingly difficult. Friends and family become frustrated trying to communicate with someone who has a hearing impairment, and invitations to participate in social activities dwindle. -Identify the extent and cause of the social isolation. Help to differentiate the reality of the isolation and its cause from the client's perception of isolation. Clients with impaired hearing may be unaware that they are isolated. Identifying factors that contribute to isolation may provide the needed impetus to remedy the hearing loss. -Encourage client to interact with friends and family on a one-to-one basis in quiet settings. Clients with impaired hearing are more successful in understanding conversations that take place in small groups and quiet settings. -Treat the client with dignity and remind friends and family that a hearing deficit does not indicate loss of mental faculties. Inappropriate responses due to a hearing deficit can cause others to perceive the client as "stupid" or demented. -Involve client in activities that do not require acute hearing, such as checkers and chess. The client has an opportunity to interact socially without the stress of straining to hear. -Refer the client to an audiologist for evaluation and possible hearing aid fitting. -Refer to resources such as support groups and senior citizen centers. These groups provide new social outlets.

Seizure Diagnostic Tests

Laboratory tests that may be ordered include a complete blood cell count, blood chemistry, urine culture, and lumbar puncture. If the client is taking any anticonvulsants, the serum drug level is monitored regularly. An EEG is often performed at a follow-up visit between seizures. A lead level, toxicology screening, and radiological tests such as a CT scan or MRI and angiography may be performed to identify a cerebral lesion or metabolic disorder in the brain.

Clinical Manifestations and Therapies Macular Degeneration

Nonexudative maculardegeneration (dry) Manifestations: -Slow progression -Need for increasingly brighter light when reading -Possible blurriness of printed words -Difficulty recognizing faces -Overall haziness in vision -Blurred or blind spot in the center of visual field; activities, such as reading and sewing, are affected. Therapies: High-dose antioxidants and zinc Exudative macular degeneration(wet) Manifestations: -Possible abrupt onset -Visual distortions -Visual hallucinations -Impaired color vision -Blurred spot in the center of visual field Therapies: Laser surgery, Photodynamic therapy The Amsler grid was developed as a diagnostic tool for AMD. Clients with wet AMD will report the same symptoms as those with dry AMD with the addition of visual distortions. Lines that are straight will appear crooked, bent, or irregular. Also, there may be a difference in the appearance of the size of objects between eyes.

Macular Degeneration Nursing Process

Nurses should be alert for clients demonstrating new and rapid onset of macular degeneration and promptly refer these clients for ophthalmological evaluation. Early intervention may preserve a greater degree of vision and slow the progress of the disease. Assessment Health history. Effect of vision changes on lifestyle and activities (e.g., ability to read, watch television, participate in work and recreational activities); family history of macular degeneration, nutrient intake, history of cigarette smoking Physical examination. General health; visual acuity, including Amsler grid. Diagnosis For clients with slowly progressive manifestations, the nursing focus is on helping the client and family members adapt to the gradual decline in vision by recommending visual aids and other coping strategies. Client education materials should be in a large-print format. Client advocacy, psychological and emotional support, and teaching/learning needs are typically of higher priority for these clients. Nursing diagnoses for the client with macular degeneration may include the following: -Risk for Injury -Risk for Ineffective Self Health Management -Fear Planning Identified outcomes of relevant to caring for the client with AMD may include: -The client will remain free from injury. -The client will express feelings related to diagnosis and reduced vision. -The client will identify strategies to promote client's self-care and daily routine. Implementation Screening and education are central to nursing care for the client with AMD. Routine ophthalmic examinations should be encouraged to detect many forms of age-related eye pathologies. A diet that is high in antioxidant vitamins and zinc may help slow the vision loss in AMD. Healthy unsaturated fats such as olive oil may help prevent vision loss. Nurses should also emphasize the importance of UVA/UVB blocking eyewear, smoking cessation, and exercise to support vision health and also to reduce the risk of cardiovascular disease. When working with the client who is experiencing severe vision loss due to AMD, nurses should assess the client for grief or fear related to the client's loss of vision and anxiety related to the disease and treatment options. -Explain the nature of the condition and help the client determine the extent to which it is affecting daily life. -Attend to verbalized concerns. Address questions factually and completely. For many clients, fear of blindness is second only to fear of cancer. Careful listening and teaching and a caring, understanding attitude can help the client deal with this fear. -Assess for factors that may interfere with the client's ability to provide self-care, including environmental barriers that compromise safety. -Recommend visual aids when appropriate (e.g., magnifyingglass and large-type books). -Teach client and caregiver about the benefits of a diet high in antioxidants, such as leafy green vegetables and fish; also offer information about supplements. -Offer resources on smoking cessation. -Explain the need for regular eye exams. -Assess for other care needs that may be impacted by vision changes. Some healthcare needs, such as insulin injections, may suggest the need for home health or nursing care postoperatively. -Encourage use of other senses, such as touch. Touch allows the client to become familiar with objects. -Encourage use of electronic audio equipment. Radio and television can help the client remain aware of day and time and ensure the client access to emergency newsservices. -As necessary, consult with occupational therapy for assistive devices. -Make referrals to appropriate home health agency. -Educate family and caregivers and provide resources.

Lifespan Considerations Cataracts in Children

Some cataracts are present at birth, whereas others are acquired during childhood. Some of the causes of acquired cataracts include retinopathy of prematurity, metabolic diseases such as galactosemia, and long-term use of corticosteroids. A major cause of congenital cataracts in the past was congenital rubella syndrome, the mother's infection with rubella during gestation. Now that children and women receive the rubella vaccine, very few cases of cataracts result from congenital rubella syndrome.

Alzheimer's Disease Nursing Process

The nurse's primary goal in working with individuals with AD is to provide a safe, supportive environment that meets their changing abilities and needs. The nurse must also take steps to support clients' family members as they cope with the emotional and physical demands of caring for a loved one with AD. Assessment Like all client assessments, a nurse's assessment of individuals with AD consists of two main elements: a health history and a complete physical examination. During the history portion of the assessment, the nurse should take care to ask about factors associated with an increased likelihood of AD, including: -Family history of AD and other dementias -Personal history of stroke, cardiovascular disease, brain injury, or brain infection -Changes in behavior, cognition, memory, and/or communi- cation ability -Alterations in mood -Disrupted sleep patterns -Difficulty performing activities of daily living -Drug and alcohol use -Possible exposure to environmental toxins Next, during the physical assessment, the nurse should evaluate the client's height, weight, vital signs, and overall physical condition. Throughout the exam, the nurse should remain alert for possible signs of abuse, neglect, depression, malnutrition, elimination difficulties, and alterations in skin and tooth integrity, as AD increases the risk for all of these. The nurse should also inquire about any medications and supplements the client is taking, both to check for possible interactions and to assess whether any of these substances increase the client's risk for injury. Some blood pressure medications, for example, may contribute to an increased likelihood of dizziness, disorientation, and falls. For clients with AD, a thorough mental status examination is critical. Of these tools, the Mini-Mental State Exam (MMSE) is particularly useful as it quickly evaluates multiple areas of functioning and is appropriate for clients of all ages. Following the health history, physical exam, and mental status exam, several steps may be appropriate. For an individual suspected of having but not yet diagnosed with AD, laboratory testing and imaging studies may help rule out other health problems. When working with a client who has already been diagnosed with AD, the nurse should note any significant changes in the client's symptoms since the last assessment. The nurse must also investigate the client's living situation, including caregiver ability and availability. Lastly, caregivers themselves should be assessed for signs of emotional and/or physical distress, as they are increasingly likely to experience burnout as the client's condition deteriorates. Diagnosis Appropriate nursing diagnoses for clients with AD vary by stage of the disease. Some common diagnoses for individuals in the earlier stages of AD are as follows: -Risk for Injury -Imbalanced Nutrition: Less Than Body Requirements -Impaired Memory -Chronic Confusion -Ineffective Denial -Anxiety -Hopelessness As the disease progresses, additional nursing diagnoses may also be applicable. Note that some of these diagnoses, especially those related to anxiety and role strain, can also be applied to caregivers and should be addressed by the nurse. Examples of nursing diagnoses that may be appropriate for inclusion in the nursing plan of care for the client with AD include the following: -Risk for Aspiration -Self-Care Deficit (Bathing, Dressing, Feeding, and/or Toileting) -Impaired Social Interaction -Impaired Verbal Communication -Functional Urinary Incontinence -Impaired Physical Mobility -Wandering -Impaired Swallowing -Risk for Compromised Human Dignity -Risk for Caregiver Role Strain Planning The planning portion of the nursing process involves identifying desired client outcomes and formulating steps for achieving them. Appropriate goals and actions will vary depending on a client's physical and mental status and current living situation, and they may include the following: -Client will utilize lists, calendars, and other memory aids as needed. -Client will perform instrumental activities of daily living with caregiver assistance. -Client will remain free from injury. -Client will exhibit reduced anxiety, agitation, and restlessness. -Client will take all medications as prescribed. The nurse should also consider caregiver and family needs during the planning process. Some suggested outcomes are as follows: -Caregiver will utilize respite care resources as necessary. -Caregiver will learn effective strategies for coping with the stresses of supporting a loved one with AD. -Caregiver will obtain the sleep and nutrition necessary to preserve personal health. Implementation Providing care to clients with AD becomes increasingly challenging as their condition worsens. Further complicating care is the fact that clients in the moderate to late stages of the disease no longer have the cognitive capacity necessary to consent to care. For this reason, clients should be encouraged to make their wishes known before they lose the ability to do so. Nurses should emphasize the importance of advance directives and planning for long-term institutional care. Implementation involves more than simply encouraging clients to plan for their future. The nurse must also engage in interventions aimed at maintaining clients' physical and cognitive functioning to the greatest degree possible. Most interventions fall into several broad categories, as described in the following sections. Promote Effective Coping Strategies Clients and caregivers require assistance coping with the mem- ory loss that accompanies early-stage AD. Cuing devices that remind clients of important people, events, and actions may be helpful. The nurse might encourage individuals with AD to keep a detailed appointment calendar, write to-do lists, post notes around their home, or have a friend or family member remind them of upcoming events. Electronic devices, such as alarm clocks and cellular phones, can be programmed to deliver reminders at designated times. Less complex assistive tools, such as date-labeled medication boxes and lists of loved ones' contact information, may also be useful. Because stress aggravates memory loss, nurses should encourage clients to engage in relaxation- promoting activities such as meditation, exercise, and therapeutic touch. Referral to a psychologist or support group can also help clients cope with emotional turmoil related to memory loss. Similarly, a number of interventions can greatly assist clients who are coping with chronic confusion. One easy action is to label frequently used objects and locations, like keys, doors, and drawers. Another is to minimize environmental stimuli, including loud noises, flashing lights, and rapid movements. Large, easy-to-read clocks and calendars can help orient confused individuals to time and date, as can frequent verbal references to what season or day it is. A variety of interpersonal actions are also useful in limiting confusion. Prevent Injury Because of the many physical and mental challenges associated with AD, affected individuals are at particularly high risk of harm from falls. Thus nurses should take steps to minimize clients' likelihood of falling, such as clearing the environment of tripping hazards (e.g., electrical cords and throw rugs); making sure clients have sturdy, well-fitting shoes; and applying skid-proof tape to stairs and slick surfaces. Use of night-lights, brighter daytime lighting, or glow-in-the-dark floor tape may be appropriate in hard-to-navigate areas. The nurse should also check whether clients' medications increase their risk of balance problems, as well as work with physical therapists to ensure clients engage in exercises that support strength and mobility. A number of other injury-prevention measures have nothing to do with falls. For example, nurses should ensure that potential hazards, such as knives, guns, medications, matches, lighters, and toxic chemicals, are inaccessible to individuals with moderate to late-stage AD. In some cases, it may be necessary to disconnect or place childproofing devices on a client's stove or oven. Doors should have a double-lock mechanism or alarm to prevent clients from accessing forbidden areas or wandering away, and areas such as balconies and porches should be modified for increased safety. Fenced yards with locked gates are another good wandering deterrent. Finally, for everyone's safety, individuals with AD must not be allowed to drive. Unfortunately, many clients refuse to willingly surrender their car keys, and they become angry when their family raises the topic. In such cases, the nurse can take several steps to assist family members in limiting their loved one's access to automobiles. For example, the nurse can reinforce the dangers of driving in conversations with the client or can offer the client a self-assessment tool for gauging his ability to drive. The nurse can also work with the physician to contact the local bureau of motor vehicles, asking that the client's driving ability be reevaluated or his license revoked for medical reasons. Promote Balance Between Rest and Activity In the later stages of AD, restless behavior is common in the afternoons and evenings due to sundowning. Overstimulation can also lead clients to become agitated. Examples of nursing interventions that may prevent fatigue and agitation include the following: -Watch clients for early signs of restless, tiredness, or anxiety. When clients seem agitated or fatigued, take action quickly. Consider moving them to a quiet place where they can rest and calm themselves. -Prevent fatigue by giving clients adequate time to rest throughout the day. Consistent scheduling of daily activities also helps clients feel more familiar with their surroundings and therefore less anxious. -Set aside "quiet time" in the late afternoon and early evening. Low lighting and calming activities like listening to music can help decrease the likelihood of sundowning. -If clients cannot achieve relief of their anxiety or agitation, look for possible physical causes, such as electrolyte imbalance, infection, or fever; then take action as appropriate. Promote Psychosocial Wellness Clients with AD often suffer from heightened anxiety and restlessness, both before and after major cognitive and physical declines become apparent. Sudden life changes can exacerbate this problem and lead to further deterioration. For example, events such as hospitalization, moving, or a change in caregivers may precipitate confusion and declines in cognitive and physical health. To help minimize the risk of such declines, all foreseeable life transitions should be well planned and carried out in a way that minimizes client anxiety. Hopelessness and depression are also common among clients with AD and their caregivers, and these emotions may wax and wane as the disease progresses. A variety of nursing interventions can help manage feelings of hopelessness and thereby increase clients' and families' quality of life. For instance, the nurse should provide realistic information about the disease at a level appropriate to the client's and/or family's level of understanding. All parties should feel free to express their feelings in a judgment-free environment that promotes mutual respect. The nurse should also foster open discussion and further questions, as clear communication based in fact (rather than myth) is central to good decision making. Similarly, clients should be encouraged to make as many of their own health decisions as possible, both to increase their autonomy and reduce the burden on family members. Lastly, the nurse should encourage clients and families to seek counseling and/or spiritual guidance if they so desire. Facilitate Stress Management for Caregivers Caregivers of individuals with AD experience a wide range of stressors that can lead to feelings of fatigue and isolation. Often, a client's spouse is the primary caregiver, and this individual is also struggling with fear of the future and eventual loss of a mate. Other times, the burden of care falls on the client's children, who may already be overwhelmed by families of their own. In either case, caregivers may turn to the nurse for support. When this happens, the nurse should refer them to various community resources as appropriate. The nurse should also validate the caregivers' emotions, telling them that what they're feeling is normal and not a sign of weakness or being a bad person. This is especially important when caregivers express feelings of guilt for wanting a "break" from their caregiving duties. In such situations, referrals to respite care agencies can be useful in promoting and preserving caregivers' mental, physical, and emotional health.

Community-Based Care Clients With Hearing Loss

Teaching for home and community-based care for the client with hearing loss focuses on managing the deficit and developing coping strategies. Many adults with hearing loss are not employed and those who are typically work in low-skilled jobs. The loss of the ability to communicate with other people can have a profound impact on everyday life and create feelings of frustration and loneliness. This is especially prevalent in clients with congenital hearing loss if they have not been given the ability to learn sign language. Early detection and intervention is critical for children with hearing loss or deafness to minimize the impact of this deficit. Screening by their healthcare provider as well as school screenings can help with early detection. Speech/language therapists can work closely with children, their parents and their schools to maximize their educational success. Families of children with hearing loss should be given the opportunity to learn sign language with their child. Hearing aids (if appropriate), development of lip-reading skills, sign language, and use of printed text can help a child be successful at school.

Cataracts Surgery

Surgical removal is the only treatment used at this time for cataracts; no medical treatment is available to prevent or treat them. If the client presents with bilateral cataracts, surgery is performed on only one eye at a time. If an intraocular lens (an artificial lens to replace the diseased lens of the eye) is to be implanted during surgery, the corneal curvature will be measured via keratometry and the anteroposterior diameter of the eye will be measured via A-scan prior to surgery. This allows the healthcare team to determine the proper lens needed for the intraocular lens implant. Various lens choices are available, based on the client's vision pathology and needs. These include monofocal lenses, multifocal (accommodative) lenses, and toric lenses. The surgeon must make more careful measurements for a patient who has previously undergone LASIK surgery. Surgical removal of the cataract and lens is indicated when the cataract has developed to the point that vision and activities of daily living are affected. A mature cataract also may be removed when it causes a secondary condition such as glaucoma or uveitis. Cataract surgery typically is done on an outpatient basis using local anesthesia. If general anesthesia is required, the client may be hospitalized overnight. Extracapsular extraction, in which the anterior capsule, nucleus, and cortex of the lens are removed leaving the posterior capsule intact, is the procedure of choice. Using an operating microscope, the surgeon makes a small incision at the edge of the cornea and extracts the lens intact or via emulsification and aspiration. In the latter technique, ultrasound vibrations are used to break the lens material into fragments (phacoemulsification), which are then suctioned out of the eye. Phacoemulsification lens removal requires a smaller incision and usually is preferred over extracting the lens intact. The remaining capsule supports the lens implant and protects the retina. After removal of the lens, the eye can no longer focus light on the retina and vision is seriously affected. Usually a plastic, acrylic, or silicone intraocular lens is implanted at the time of surgery. This implant rapidly restores binocular vision and depth perception. In most cases, following extracapsular lens removal, the intraocular lens is positioned in the posterior capsule behind the iris. This is called a posterior chamber lens. In some cases, the intraocular lens is positioned in front of the iris with an anterior chamber lens. A secondary procedure called a limbal relaxing incision can be performed at the same time as the cataract surgery or at another time. This helps clients reduce or even eliminate the need for eyeglasses. Small incisions are made at opposite ends of the cornea, which allows its shape to be rounder or more symmetrical. If an intraocular lens cannot be implanted, convex corrective glasses or contact lenses may be used to correct vision after cataract removal. Although contact lenses can provide excellent vision correction following cataract surgery, they may be difficult for some clients to adapt to or manipulate. The client with a preexisting refractive error may continue to require corrective lenses and often needs a prescriptive change after surgery. Complications of cataract surgery are unusual and occur in less than 1% of the surgeries. Potential complications include loss of vitreous humor, corneal edema, increased intraocular pressure, hemorrhage, inflammation or infection, retinal detachment, and displacement of the implanted lens. Between 10% and 50% of clients who undergo extracapsular extraction may develop opacification of the remaining posterior capsule 3-5 years after surgery (secondary cataract). Vision can be restored with a posterior capsulotomy (creation of an opening with a laser for light to pass through the opacified capsule) or surgical incision into the posterior capsule to allow light to reach the retina

ASD Clinical Manifestations

The essential features typically become apparent by the time a child is 3 years of age. They reflect impairments in the following: -Social interactions -Communication -Ability to adapt to new situations -Attention span and ability to organize responses to situations Social interactions are always complex and involve perceptions of the other individual as well as social behaviors. The client with ASD does not learn the common characteristics of these social interchanges. As a result, these individuals may be unable to converse normally, may fail to initiate conversations, and may fail to understand or observe nonverbal behavior. Children with ASD manifest disturbances in the rate or sequence of development, with onset of abnormal functioning in at least one of the following areas prior to age 3: social interaction, language used in social interactions, and imaginative play. A primary finding is impairment in social interactions, particularly as this pertains to relating to others or responding to social and emotional cues. In addition, stereotypy, or rigid and obsessive behavior, may be observed. Characteristically, these repetitive behaviors in affected children include head banging, twirling in circles, biting themselves, and flapping their hands or arms. Frequently, a child's behavior is self-stimulating or self-destructive. Responses to sensory stimuli are frequently abnormal and include an extreme aversion to touch, loud noises, and bright lights. Emotional lability (rapid, significant mood changes) is common. Communication difficulties or delays in speech and language are common and are often the first symptoms that lead to diagnosis. Absence of babbling and other communication by 1 year of age, absence of two-word phrases by 2 years, and deterioration of previous language skills are characteristic of autism. Language acquisition, including verbal and nonverbal communication pat- terns, such as eye contact, will vary based on the severity of the disorder. Some children and adults with ASD can participate fully in conversations, but may show characteristic behaviors such as marked lack of eye contact and lack of emotional reciprocity. They may or may not understand humor and other subtleties of language. For children with ASD, speech patterns are likely to show certain abnormalities, such as the following: -Using you in place of I -Engaging in echolalia (a compulsive parroting of a word or phrase just spoken by another) -Repeating questions rather than answering them -Being fascinated with rhythmic, repetitive songs and verses. Behaviors of children with autism spectrum disorders show several differences from other children's behaviors. Children with ASD may have a great difficulty dealing with new situations and typically show agitation and withdrawal when routines are changed. Children with ASD do not commonly explore objects, but have stereotyped behaviors. They may line up objects, play with the same objects over and over, and have certain rituals that must be performed. They often become upset if these normal routines are disrupted. Rituals may involve eating only certain types or colors of foods or eating in specific patterns. Clients with ASD may manifest disturbances in the rate or sequence of development. Pediatric clients may be cognitively impaired, but they can demonstrate a wide range of intellectual ability and functioning. Cognitive impairment may be manifested early in life by slow developmental progression, particularly in social skills. Some children with ASD are of at least average intelligence, and some are highly gifted. Some children with autism spectrum disorder are impaired in particular areas of development, while others are above normal. About 25% have macrocephaly, with reduced head size at birth, followed by excessive growth at 1-2 months and 6-14 months. However, most children with ASD have a normal appearance.

Cerebral Palsy Patho and Etiology

The exact insult leading to CP may not be identifiable if it occurs during the prenatal period. After delivery, the cause of the insult is more likely to be identified. Insults may include any combination of hypoxic-ischemic encephalopathy, vascular, metabolic, infectious, toxic, teratogenic, traumatic, or genetic events. The insult alters muscle tone, muscle stretch reflexes, postural reactions, and primitive reflexes; it may also result in seizures, mental retardation, and/or hearing problems. The outcome depends on the area of the brain affected, the severity of the event, the duration of the insult, and the child's age at the time of the event. The exact pathogenesis is multifactorial and not clearly understood. It is believed that damage is done to the motor areas of the brain, impairing the body's ability to control movement and adjust posture appropriately. CP is neither contagious nor inherited, and it is not progressive. It cannot be cured, but it can be managed. CP often is identified when children fail to meet expected developmental milestones and diagnostic testing is ordered to pinpoint the reason for the delay. Symptoms and manifestations vary from person to person depending on the exact neurological impact of the event. Etiology Most CP cases are believed to be caused by congenital, hypoxic, ischemic, or infectious intrauterine insults to the central nervous system (CNS). The risk for CP is increased when intrauterine infection (chorioamnionitis) is documented. Injury to the immature periventricular white matter in fetuses and premature infants is thought to be the most common cause of CP. At one time, hypoxia was considered the primary culprit for CP, but studies revealed that premature birth is responsible for most cases. Birth defects and adverse labor events also are significant contributors to CP. The rate of CP increases with decreasing gestational age. Infants born before 27 weeks' gestational age are diagnosed with CP at a much higher rate than are those with a higher gestational age. Birth asphyxia is believed to account for a significant number of CP cases, but still far fewer than previously believed. No reduction of incidence of CP has been noted since the use of electronic fetal heart rate monitoring was implemented. In young children, CNS infection and head trauma are the major sources of acquired brain injury and subsequent motor dysfunction.

Alzheimer's Disease Clinical Manifestations

The initial symptoms of AD emerge gradually and may be almost unnoticeable. The first manifestation is usually subtle memory loss that becomes increasingly apparent as time passes. Other early signs include difficulty finding words and perform- ing familiar tasks; impaired judgment and abstract thinking; disorientation to time and place; and frequently misplacing things. These alterations go beyond the changes sometimes seen with normal aging, as described in The Concept on Cognition. Changes in mood or personality are also common. Early in the course of AD, many individuals exhibit decreased initiative, odd behavior, and signs of depression. As the disease progresses, the continued deterioration in clients' cognition is accompanied by physical decline. At some point, affected individuals lose the ability to perform everyday tasks and must rely wholly on their caregivers. Because many manifestations of AD are similar to those of other conditions, it is important to rule out other disease processes before concluding a client has AD One useful tool for remembering conditions that mimic AD is the DEMENTIA mnemonic: Drug or alcohol use Emotional disorders Metabolic or endocrine disorders Eye and ear dysfunctions Nutritional deficiencies Tumors, trauma, or toxins Infections Atherosclerotic effects on the heart and brain Individuals with AD progress through several stages of the disease. In general, clients with FAD move from the initial to the later stages of the disease faster than clients with sporadic AD. However, individuals' rate of progression is affected by a variety of factors, including their overall health and the type of care they receive following diagnosis. In the past, AD was described in terms of three stages: stage 1 (early), stage 2 (moderate), and stage 3 (severe). Recently, many practitioners have abandoned this system in favor of the seven-stage model proposed by Dr. Barry Reisberg.

Clinical Manifestations and Therapies Seizure Disorders

The length of a seizure, especially of a generalized seizure, is important because the airway may be compromised during the tonic phase. The initial manifestations of the tonic phase of a generalized seizure are unconsciousness and continuous muscular contraction. The basal metabolic rate rises during the peak of seizure activity, increasing the body's demand for oxygen and glucose. The client may become pale or cyanotic as a result of hypoxia. The client also may become hypoglycemic if glucose demand is excessive. The symptoms of a seizure depend on its type and duration. Seizures are classified into two types: partial (focal) seizures and generalized seizures. Tonic-clonic seizures are the most common seizure type in children, characterized by alternating repetitive tonic-clonic activity. The tonic phase is followed by the clonic phase, characterized by alternating muscular contraction and relaxation. During the postictal period following seizure activity, LOC is decreased and the client is often sleepy but arousable. The length of the postictal period varies. An aura may provide an early warning sign of a seizure and may be manifest as any type of sensory alteration ranging from odor and taste to vision. When the client recognizes the pattern of an aura, he or she may have time to avoid injury by getting to the floor. Febrile seizures involve generalized tonic-clonic movements that last less than 15 minutes. Simple partial seizures involve activation of only a restricted part of one cerebral hemisphere. Manifestations: No alteration in consciousness occurs. Typically only motor portion of cortex is affected causing recurrent muscle contractions of face or contralateral part of body. Motor movement may be confined to one area. If it spreads sequentially to adjacent parts it is called a Jacksonian march or Jacksonian seizure. If sensory portion is involved, manifestations may include abnormal sensations or hallucinations. Disruption in autonomic nervous system may result in tachycardia, flushing, hypotension, or hypertension. Psychic symptoms such as a sense of déjà vu or inappropriate fear or anger may be experienced. Therapies: Antiepileptic medications. Maintain client safety during seizure. Assess exact manifestations experienced by client and document fully. Vagal nerve stimulation therapy Complex partial seizures involve activation of only a restricted part of one cerebral hemisphere, usually originating in the temporal lobe. Manifestations: Often proceeded by an aura, which may be visual, auditory, an odd smell, or psychic in nature. Impaired consciousness lasts for several hours before full consciousness is regained. Exhibits repetitive nonpurposeful activity such as lip smacking, aimless walking, or picking at clothing called automatisms. Amnesia is common after seizure. Therapies: Antiepileptic medications Maintain client safety. Vagal nerve stimulation Resection of epileptogenicfocus, such as the temporal lobe, may be considered. Absence seizures (petit mal) involve both hemispheres of the brain as well as deeper structures such as thalamus, basal ganglia, and upper brainstem. Manifestations: Level of consciousness is impaired. Sudden brief cessation of all motor activity is accompanied by blank stare and unresponsiveness. More common in children. Usually lasts 5-10 seconds, sometimes as long as30 seconds. Vary from occasional to several hundred per day. Therapies: Antiepileptic medications. Maintain client safety. Tonic-clonic seizures are the most common type seen in adults. Manifestations: Warning aura may proceed seizure activity (visual, gustatory, auditory, visceral, or sense of uneasiness). Sudden loss of consciousness. Tonic phase: Sharp tonic muscle contraction forcing air out of the lungs which may cause client to cry out. Loss of postural control causing client to fall in opisthotonic posture. Muscles are rigid with arms and legs extended and jaw clenched. Urinary incontinence is common and may be accompanied by bowel incontinence. Breathing ceases and cyanosis develops. Pupils fixed and dilated. Lasts 15-60 seconds. Clonic phase follows characterized by: Alternating contraction and relaxation of muscles in all extremities. Hyperventilation. Eyes roll back. Client froths at the mouth. Varies in duration and subsides gradually generally 60-90 seconds. Postictal phase: Client remains unconscious and unresponsive to stimuli. Relaxed and breathes quietly. Regains consciousness gradually and may be confused and disoriented on waking. Headache, muscle ache, fatigue often reported. May sleep for several hours. Amnesia is usual both for the seizure and several minutes before seizure activity. Therapies: Antiepileptic medications. Maintain client safety. Driving privileges will be suspended until seizure activity is controlled and client is seizure free for a period of time determined by state statutes. Helmets may be recommended to prevent head injury until seizure activity is controlled. Do not restrain client. Pad bed rails. Diazepam, lorazepam, or phenobarbital may be administered during seizure to limit length of seizure. Status epilepticus Manifestations: Continuous seizure activity with only very short periods of calm between intense and persistent seizures. Seizures may be any type but most often are generalized tonic-clonic. Client is in great danger of hypoxia, acidosis, hypoglycemia, hyperthermia, and exhaustion if seizure activity is not halted. Therapies: Provide immediate interventions to preserve life. Establish and maintain an airway. Administer 50% glucose to prevent hypoglycemia. Diazepam or lorazepam is administered IV and repeated every 10 minutes until seizure activity stops. Administer antiepileptics such as phenytoin. Phenobarbital may also be administered.

Cataracts Diagnostic Tests

The simplest test to aid in the diagnosis of cataracts is the visual acuity test. The Snellen and Rosenbaum charts are used. A dilated eye exam with either an ophthalmoscope or slit-lamp examination provides a magnified view of the structures of the eye.

Alzheimer's Disease Diagnostic Tests

There is no definitive way to diagnose AD other than performing a brain autopsy. Thus practitioners rely on differential diagnosis, ruling out potential causes of a client's symptoms until AD remains the most likely explanation. In doing so, they use multiple techniques, including blood tests for drugs, alcohol, toxins, and metabolic or endocrine imbalances, as well as screenings for infection, nutritional deficiencies, eye and ear problems, and emotional disorders. MRI, CT, and other brain-imaging studies may be conducted to look for tumors, impaired blood flow, fluid accumulation, or stroke damage. In some cases, genetic testing may be useful, and in all cases, clients should be asked about their family history of AD. Of course, ongoing interviews are critical, as they allow practitioners to track changes in a client's mental and physical status.

Peripheral Neuropathy Pharmacologic Therapy

There is no single drug to treat pain resulting from peripheral neuropathy, because drug therapy is individualized and based on comorbidities, extent of nerve damage, and nerve affected. Medications used include pain relievers, anticonvulsants, and antidepressants. Pain relievers. For mild symptoms, over-the-counter medications such as acetaminophen or ibuprofen may be helpful. More severe symptoms may require the use of an opiate. Anticonvulsants. In recent years the use of anticonvulsants to treat nerve pain has increased. The mechanism of action related to nerve pain is poorly understood, but it is thought that anticonvulsants may block pain receptors in the CNS. Some examples of anticonvulsants used in treating nerve pain include carbamazepine (Carbatrol, Tegretol), gabapentin (Neurontin), pregabalin (Lyrica), and topiramate (Topamax). Nursing Considerations: Teach client about side effects of dizziness and drowsiness. Teach client to avoid grapefruit and grapefruit juice. Teach client to avoid antacids. Women who are breastfeeding or may become pregnant should avoid using these drugs. Antidepressants: Tricyclic antidepressants are thought to activate a descending serotonergic (5-HT1) antinociceptive pathway that creates an endogenous pain modulation system. This action is different from how tricyclic antidepressants work in the treatment of depression. Some examples of tricyclic antidepressants are amitriptyline (Elavil) and nortriptyline (Pamelor). The serotonin-norepinephrine reuptake inhibitor (SNRI) duloxetine (Cymbalta) blocks the depletion of serotonin and norepinephrine in the CNS, which may help modulate pain receptors. Administer with food. Both tricyclic antidepressants and SNRIs take 4-6 weeks to reach therapeutic plasma levels. They also have side effects that include dizziness, drowsiness, nausea, and decreased appetite. Nursing Considerations: Teach clients about side effects of dizziness and drowsiness, nausea, and decreased appetite. May take 4-6 weeks for therapeutic plasma levels to be achieved. Take at bedtime to avoid drowsiness. Lidocaine patch. A local anesthetic that is absorbed through the skin. Serious side effects can occur including hives, confusion, weakness, fainting, and swelling of the lips, face, tongue, or throat

Macular Degeneration Surgery

Wet AMD is treated with laser surgery or photodynamic therapy. Although these treatments do not cure the disease, they may slow the rate of vision loss. In laser surgery, fragile blood vessels are destroyed, preventing bleeding. In photodynamic therapy, verteporfin, a drug that tends to adhere to the surface of new blood vessels, is injected systemically. Shining a light into the affected eye activates the drug and destroys new blood vessels. Risks include damage to surrounding healthy tissue, some vision loss, and continued growth of new vessels. Since the introduction of antiangiogenic drug therapy, surgical therapy is less common.

Alzheimer's Disease Prevention

There is no way to prevent AD, but certain actions appear to limit an individual's risk. One important step is weight control, as long-term studies have shown that obesity doubles an individual's risk of AD. Eating a diet that is low in cholesterol and saturated fat reduces the likelihood of obesity. It also helps pre- vent cardiovascular disease, high blood pressure, and high cholesterol, all of which increase the likelihood of AD. Regular exercise is another behavior that combats obesity, promotes good circulation and cardiovascular health, and therefore protects against AD. In addition to avoiding saturated fats and cholesterol, individuals should seek to consume certain protective foods. Vitamin E, omega-3 fatty acids, and antioxidants appear to protect the brain against AD, and they also reduce cardiovascular dis- ease risk. Vitamin C, vitamin B12, and folate may also exert a protective effect. Use of drugs and alcohol can both limit and increase a person's chances of AD, depending on the substance and amount consumed. Cigarette smoking was previously thought to protect against AD, but recent research suggests the opposite is true. Drinking moderate amounts of green tea and red wine seems to interrupt formation of amyloid plaques. However, black tea and other types of alcohol do not have this effect. Similarly, long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen may help prevent AD if taken before the disease process begins, though not all evidence supports this conclusion. Finally, individuals who stay mentally and socially active have a significantly reduced risk of AD. One study found that older adults who engaged in frequent social activity cut their rate of cognitive decline by 70%. Research also suggests that greater levels of cognitive activity in early and middle adulthood can slow or perhaps even stop beta-amyloid deposition in the brain. Examples of beneficial activities include word puzzles, games, and reading.

ASD Risk Factors

Without a specific etiology, determining risk for autism is difficult. However, some factors appear to be linked. A maternal age of 40 or older and a paternal age of 50 and above increase the risk that a child will be born with autism. Maternal smoking or the use of alcohol, valproic acid, or misoprostol during pregnancy also increases rates of autism. Children with genetic abnormalities such as tuberous sclerosis, fragile X syndrome, Down syndrome, congenital rubella syndrome, and neurofibromatosis have an increased occurrence of autism. Boys have a higher rate of ASD than girls. Premature or low-birth-weight babies carry a higher risk

Tinnitus

is the perception of sound or noise in the ears without stimulus from the environment. The sound may be steady, intermittent, or pulsatile and is often described as a buzzing, roaring, or ringing. Tinnitus is usually associated with hearing loss (conductive or sensorineural); however, the mechanism producing the sound is poorly understood. It is often an early symptom of noise-induced hearing damage and drug-related ototoxicity. Tinnitus is especially associated with salicylate, quinine, or quinidine toxicity. Other etiologies include obstruction of the auditory meatus, presbycusis, middle or inner ear inflammations and infections, otosclerosis, and Ménière disease. Most tinnitus, however, is chronic and has no pathological importance. Tinnitus can be very stressful and cause anxiety and/or depression for the individual experiencing it. Individuals with chronic tinnitus should not have their distress minimized Early identification of hearing loss is a key element in successful treatment. Detection of hearing loss in infants is important to ensure optimal development. Clients need to know the risk for hearing damage and how to prevent it. Awareness of the effects of noise exposure, especially when combined with the ototoxic effects of aspirin or other drugs, is important in preventing sensorineural hearing loss. Therapies: Treat underlying cause. Tinnitus maskers such as ambient noise.

Hearing Impairment Diagnostic Tests

whisper test, otoscope examination, tympanogram, and use of a tuning fork to perform the Rinne and Weber tests