Nursing of Adults with Medical

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Nursing of Adults withMedical Surgical
Conditions

• Neurological
• Disorders

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Laboratory and Diagnostic Exams

• Blood and Urine
• Culture
• Urinary tract infection
• Drug screens
• Rule out drugs as cause of symptoms
• Arterial Blood Gases
• Monitor the oxygen content of the blood
• Low levels indicate altered breathing patterns

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• Cerebrospinal Fluid
• Normal Values
• Specific gravity 1.007
• pH 7.35 to 7.45
• Chloride 120 to 130 mEq/L
• Glucose 50 to 75 mg/dl
• Pressure 80 to 200 mm water
• Total Volume 80 to 200 ml
• Total Protein 5 to 45 mg/dl
• Gamma globulin 6 to 13 of total protein
• Cell Count
• RBC None
• WBC 0-10 cells (lymphocytes and monocytes)

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• Cerebrospinal Fluid (Cont)
• Elevated lymphocytes may indicate infection
• Decreased chloride and glucose levels may
  indicate tuberculosis meningitis
• Culture or smear is done to determine the
  causative organism in meningitis
• Protein is elevated with degenerative disease or
  brain tumors
• Blood indicates hemorrhage from somewhere in the
  ventricular system
• Protein electrophoresis may give evidence of MS

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• Computed Tomography (CT) Scan
• Detects pathological conditions of the cerebrum
  and spinal cord
• May be done with or without contrast
• Brain Scan
• Uses radioactive isotopes
• MRI Scan
• Uses magnetic forces to image the cerebrum and
  spinal cord

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• PET Scan
• Positron Emission Tomography
• Used following stroke, Alzheimers, epilepsy and
  Parkinsons
• Injection of deoxyglucose with radioactive
  fluorine is given
• Color scan is done different shade can be
  translated into different pathological conditions

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• Lumbar Puncture
• Obtain CSF for examination
• Relieve pressure
• Inject dye or medication
• Contraindicated in patients with increased
  intracranial pressure

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• Electroencephalogram (EEG)
• Used to provide evidence of focal or generalized
  disturbances of brain function by measuring the
  electrical activity of the brain
• Epilepsy, mass lesions, cerebrovascular lesions
  and brain injury
• Procedure
• Patient is kept awake the night before
• Hair and scalp must be clean
• Electrodes are placed on the scalp

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• Myelogram
• Used to identify lesions in the intradural or
  extradural compartments of the spinal canal by
  observing the flow of radiopaque dye through the
  subarachnoid space.
• Used to diagnose herniated or protruding
  intervertebral disk. Spinal tumors, adhesions,
  bony deformations, and arteriovenous
  malformations
• Lumbar puncture is performed, dye injected, and
  fluoroscopic and radiopaque films are taken

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• Angiogram
• Used to visualize the cerebral arterial system by
  injecting radiopaque material
• Allows the detection of arterial aneurysms,
  vessel anomalies, ruptured vessels, and
  displacement of vessels by tumors or masses

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• Carotid Duplex
• Uses combined ultrasound and pulsed Doppler
• Noninvasive study that evaluates carotid
  occlusive disease
• Electromyogram (EMG)
• Used to measure the contraction of a muscle in
  response to electrical stimulation
• Provides evidence of lower motor neuron disease
  primary muscular disease and defects in the
  transmission of electrical impulses

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• Echoencephalogram
• Uses ultrasound to depict the intracranial
  structures of the brain
• Detects ventricular dilation and a major shift of
  midline structures in the brain as a result of an
  expanding lesion

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Headaches

• Etiology/Pathophysiology
• Skull and brain tissues are not able to feel
  sensory pain
• Pain arises from the scalp, blood vessels,
  muscles, dura mater, and sinuses
• Vascular Headaches
• Migraine
• Vessels are dilated
• Hypertensive
• Excessive pressure
• Tension Headaches
• Psychological problems
• tension, stress,
• Cervical arthritis
• Traction-Inflammation Headaches
• Infection, intracranial or extracranial causes,
  occlusive vascular structures, temporal arteritis

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Headaches

• Signs Symptoms
• Head pain
• Migraine headaches
• Prodromal (early s/s)
• visual field defects, experiencing unusual smells
  or sounds, disorientation, paresthesias, and
  rarely paralysis of a part of the body
• During headache
• nausea, vomiting, light sensitivity, chilliness,
  fatigue, irritability, diaphoresis, edema

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Headache

• Treatment
• Diet
• Limit MSG, vinegar, chocolate, yogurt, alcohol,
  fermented or marinated foods, ripened cheese,
  cured sandwich meat, caffeine, and pork
• Psychotherapy
• Decrease stress factors
• Medications
• Migraine Headaches
• aspirin, acetaminophen, ibuprofen
• ergotamine tartrate
• Constricts vessels
• Codeine
• Inderal

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Headaches

• Tension Headaches
• Nonnarcotic analgesics
• acetaminophen, propoxyphene, phenacetin,
  ibuprofen, and aspirin
• Traction-inflammatory Headaches
• Treat cause
• Comfort Measures
• Cold packs to forehead or base of skull
• Pressure to temporal arteries
• Dark room limit auditory stimulation

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Increased Intracranial Pressure

• Etiology/Pathophysiology
• Increase in any content of the cranium
• Cranium is rigid and nonexpandable
• Space-occupying lesions, cerebrospinal problems,
  cerebral edema

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Increased Intracranial Pressure

• Signs Symptoms
• Diplopia
• double vision
• Headache
• increases with coughing, straining, or stooping
• Decrease in level of consciousness
• disorientation, restlessness, lethargy
• Pupillary signs
• ipsilateral pupil dilation
• lesion is one hemisphere
• bilateral pupil dilation
• both halves of brain are involved

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Increased Intracranial Pressure

• Widening pulse pressure
• increased systolic and decreased diastolic B/P
• Bradycardia
• Respiratory problems
• vary related to the level of brainstem
  involvement
• High, uncontrolled temperatures
• Positive Babinskis reflex
• Toes fan out when bottom of foot is stroked
• Seizures

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Increased Intracranial Pressure

• Posturing
• decorticate
• flexion of arms, wrists, and fingers with
  adduction of arms
• decerebrate
• All four extremities in rigid extension, with
  hyperpronation of forearmsand plantar extension
  of feet
• Vomiting
• Singultus

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Increased Intracranial Pressure

• Treatment
• Treat cause if possible
• Mechanical decompression
• Craniotomy
• remove bone flap and replace
• Craniectomy
• remove bone flap and not replaced
• Internal Monitoring Devices
• Diagnose and monitor increased intracranial
  pressure
• Ventricular catheter, subarachnoid bolt or screw,
  and the epidural sensor
• produce pressure waves to indicate status of IIP

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Epilepsy or Seizures

• Etiology/Pathophysiology
• Transitory disturbance in consciousness or in
  motor, sensory, or autonomic function with or
  without loss of consciousness
• Sudden, excessive, and disorderly discharges in
  the neurons of the brain
• Results in sudden, violent, involuntary
  contraction of a group of muscles
• Hypoglycemia, infection, and electrolyte
  imbalance.

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Epilepsy or Seizures

• Types of seizures
• Grand Mal
• Generalized
• Tonic-clonic movements
• Loss of consciousness
• Petit Mal
• Sudden impairment or loss of consciousness
• Little or no tonic-clonic movement
• Vacant facial expression eye straight ahead
• Psychomotor
• Sudden change in awareness
• Behaves as if partially conscious
• May appear intoxicated
• Antisocial behavior
• exposing self or violence

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Epilepsy or Seizures

• Jacksonian-focal
• One body part is affected
• hand, foot, face
• May end in grand mal seizure
• Myoclonic
• Sudden involuntary contraction of muscle group
• usually in extremities or trunk
• No loss of consciousness
• Akinetic
• Generlaized tonelessness
• Falls in flaccid state
• Unconsciousness for 1-2 minutes

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Epilepsy or Seizures

• Signs Symptoms
• Depends on type of seizure
• Aura
• Sensation that may precede a seizure
• flashing lights, smells, numbness, tingling,
  hallucinations
• Postictal Period
• Rest period of variable length
• Groggy and disoriented
• Headache and muscle aches
• May sleep

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Epilepsy or Seizures

• Status epilepticus
• recurrent, gernalized seizure activity occurs at
  such frequency that full consciousness is not
  regained

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Epilepsy or Seizures

• Treatment
• During seizure
• Protect from aspiration and injury
• Lower to the floor
• Move away from furniture and equipment
• Turn the head to the side if possible
• Loosen clothing around neck
• DO NOT RESTRAIN
• DO NOT PUT ANYTHING IN MOUTH
• Medications
• Page 608 table 15-5
• Surgery
• Removal of brain tissue where seizure occurs

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Epilepsy or Seizures

• Adequate rest
• Good nutrition
• Avoid alcohol
• Avoid driving, operating machinery, swimming
  until seizures are controlled
• Good oral hygiene esp. if on Dilantin
• causes gingival hyperplasia
• edematous and enlarged gums
• Medical alert tag

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Multiple Sclerosis

• Etiology/Pathophysiology
• Degenerative neurological disorder
• Cause unknown
• Possibly genetic
• Most common in wet cold climates
• Demyelination of the brain stem, spinal cord,
  optic nerves, and cerebrum
• causes an interruption or distortion of the nerve
  impulse

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Multiple Sclerosis

• Signs Symptoms
• Visual problems
• diplopia
• scotomata (spots)
• blindness
• nystagmus
• Urinary incontinence
• Fatigue
• Weakness
• Incoordination
• Sexual problems
• Swallowing difficulties

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Multiple Sclerosis

• Remissions may last for a year or more
• Exacerbaions precipitated by
• fatigue
• chilling
• emotional disturbances

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Multiple Sclerosis

• Treatment
• No specific treatment
• Adrenocorticotropic hormone (ACTH)
• Steroids
• prednisone
• Deltasone or Decadron
• Valium
• Betaseron (Interferon beta-1b)
• reduces frequency of exacerbations
• Avonex (Interferon beta-1a)
• reduce neurological attacks and slow progress of
  physical disability

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Multiple Sclerosis

• Pro-Banthine
• decrease urinary frequency and urgency
• Urecholine
• antispasmodic for neurogenic bladder
• Bactrim, Septra, Macrodanitn
• Urinary tract infections

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Parkinsons Disease

• Etiology/Pathophysiology
• Deficiency of dopamine
• necessary for the normal transmission of nerve
  impulses
• Viral, toxic, vascular and genetic causes
• May be drug induced
• Reserpine, phenothiazines, haloperidol, cocaine

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Parkinsons Disease

• Signs Symptoms
• Muscular tremors
• Rigidity
• mask-like facial appearance
• monotonous speech
• drooling
• Propulsive gait
• Emotional instability
• Heat intolerance
• Decreased blinking
• Pill-rolling motions of fingers
• Bradykinesia
• slowness of voluntary movements and speech

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Parkinsons Disease
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Parkinsons Disease

• Treatment
• Medications
• side effects may be worse than disease
• Levodopa
• converted to dopamine
• Sinemet
• Artane
• Cogentin
• Symmetrol
• Surgery
• Pallidotomy
• Destroying portions of the brain that control the
  rigidity or tremor
• Human fetal dopamine cell transplants

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Alzheimers Disease

• Etiology/Pathophysiology
• Impaired intellectual functioning
• Degeneration of the cells of the brain
• Cause is unknown
• Possible genetic link

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Alzheimers Disease

• Signs Symptoms
• Early Stage
• Mild memory lapses
• Decreased attention span
• Second Stage
• Obvious memory lapses
• Esp. short term
• Disorientation to time
• Loss of personal belongings
• Third Stage
• Total disorientation to person, place, time
• Apraxia
• impaired ability to perform purposeful acts or
  use objects
• Wandering
• Terminal Stage
• Severe mental and physical deterioration

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Alzheimers Disease

• Treatment
• Medications
• Agitation
• Lorazepam
• Haldol
• Dementia
• Cognex
• Aricept
• Nutrition
• Finger foods
• Frequent feedings
• Encourage fluids

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Alzheimers Disease

• Safety
• Removing burner controls at night
• Double-locking all doors and windows
• Constant supervision

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Myasthenia Gravis

• Etiology/Pathophysiology
• Neuromuscular disorder
• Nerve impulses fail to pass at the myo-neural
  junction causes muscular weakness
• Possible causes
• Inadequate production of acetylcholine
• Excessive quantities of cholinesterase
• Non-response of the muscle fibers to acetylcholine

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Myasthenia Gravis

• Signs Symptoms
• Ocular
• Ptosis
• eyelid drooping
• Diplopia
• double vision
• Generalized
• Skeletal weakness
• Dysarthria
• Dysphagia
• Ataxia
• Bowel and bladder incontinence

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Myasthenia Gravis

• Treatment
• Anticholinesterase drugs
• Prostigmin
• Mestinon
• Corticosteroids
• May require mechanical ventilation

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Amyotrophic Lateral Sclerosis (ALS)Lou Gehrigs
Disease

• Etiology/Pathophysiology
• Motor neurons in the brainstem and spinal cord
  gradually degenerate
• Electrical and chemical messages originating in
  the brain do not reach the muscles to activate
  them

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Amyotrophic Lateral Sclerosis (ALS)Lou Gehrigs
Disease

• Signs Symptoms
• Weakness of the upper extremities
• Dysarthria
• Dysphagia
• Muscle wasting
• Compromised respiratory function
• death usually occurs due to infection

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Amyotrophic Lateral Sclerosis (ALS)Lou Gehrigs
Disease

• Treatment
• No cure
• Rilutec (riluzole)
• Helps protect damaged motor neurons
• Multidisciplinary ALS Teams
• experimental drugs
• physical, occupational, and speech therapy
• nutritional regimens
• psychological support
• Emotional support
• Mentally healthy physically wasting away

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Huntingtons Disease

• Etiology/Pathophysiology
• Overactivity of the dopamine pathways
• opposite of Parkinsons
• Genetically transmitted

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Huntingtons Disease

• Signs Symptoms
• Abnormal and excessive involuntary movements
  (chorea)
• Writhing, twisting movements of the face, limbs,
  and body
• Abnormal facial movements
• affect speech, chewing, and swallowing
• Ataxia to immobility
• Deterioration in mental functions

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Huntingtons Disease

• Treatment
• No cure pallative treatment
• Antipsychotics
• Antidepressants
• Antichoreas
• Safe environment
• Emotional support
• High calorie diet

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Cerebral Vascular Accident (CVA)

• Etiology/Pathophysiology
• Abnormal condition of the blood vessels of the
  brain
• thrombosis
• emoblism
• hemorrhage
• Results in ischemia of the brain tissue
• Underlying causes
• atherosclerosis, heart disease, hypertension,
  kidney disease, PVD, DM
• Risk factors
• obesity, high serum cholesterol, cigarette
  smoking, stress, cocaine use, and sedentary
  lifestyle

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Cerebral Vascular Accident (CVA)

• Signs Symptoms
• Headache
• Sensory deficit
• numbness or tingling
• inability to think clearly
• visual problems
• Hemiparesis
• Weakness on one side of the body
• Hemipalegia
• Paralysis on one side of the body
• Depends on area of brain affected
• Dysphasia or aphasia

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Cerebral Vascular Accident (CVA)

• Treatment
• Aneurysm
• Surgery
• tie off or clipping of aneurysm
• Thrombosis or Embolism
• Thrombolytics
• TPA, activase
• Heparin and Coumadin
• Decadron
• Neurological checks
• Feeding tube
• Physical, occupation, and/or speech therapy

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Trigeminal Neuralgia(Tic Douloureux)

• Etiology/Pathophysiology
• Degeneration of or pressure on the trigeminal
  nerve

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Trigeminal Neuralgia(Tic Douloureux)

• Signs Symptoms
• Excruciating, burning pain
• radiates along one or more of the three divisions
  of the fifth cranial nerve
• typically extends only to the midline of the face
  and head
• pain may be initiated by stimulation of trigger
  points

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Trigeminal Neuralgia(Tic Douloureux)

• Treatment
• Tegretol
• Surgical resection of the trigeminal nerve
• Avoid stimulation of face on affected side
• touching
• drafts
• hot or cold liquids

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Bells Palsy(peripherial facial paralysis)

• Etiology/Pathophysiology
• Inflammatory process involving the facial nerve
• Vasoconstriction due to ischemia, edema, or
  emotional trauma may also be a cause
• Unilateral or bilateral

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Bells Palsy(peripherial facial paralysis)

• Signs Symptoms
• Facial numbness or stiffness
• Drawing sensation of the face
• Unilateral weakness of facial muscles
• unable to wrinkle forehead, close eyelid, pucker
  lips, or retract the mouth
• Face appears asymmetric
• drooping of mouth and cheek
• Loss of taste
• Reduction of saliva
• Pain behind the ear
• Ringing in ear or other hearing loss

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Bells Palsy
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Bells Palsy(peripherial facial paralysis)

• Treatment
• Electrical stimulation
• Warm moist heat
• Steroids
• Massage of the affected area
• Exercises
• wrinkling the brow and forehead, closing the
  eyes, and puffing out the cheeks.

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Guillain-Barre Syndrome

• Etiology/Pathophysiology
• Inflammation and demyelination of the peripheral
  nervous system
• Cause is unknown
• Possibly viral or autoimmune reaction

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Guillain-Barre Syndrome

• Signs Symptoms
• Symptoms are progressive
• Progression may stop at any point
• Paralysis usually starts in the lower extremities
  and moves upward
• May include the thorax, upper extremities, and
  face
• Respiratory failure if intercostal muscles are
  affected
• May have difficulty swallowing, breathing, and
  speaking

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Guillain-Barre Syndrome

• Treatment
• Adrenocortical steroids
• Apheresis
• removal of unwanted components from the blood
  serum by a flow separator
• Mechanical ventilation
• may require tracheostomy
• Gastrostomy tube
• Meticulous skin care
• Range of motion exercises

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Meningitis

• Etiology/Pathophysiology
• Acute infection of the meninges
• Pneumococci, meningococci, staphylococci,
  streptococci, H. influenzae, and viral
• Bacterial or aseptic

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Meningitis

• Signs Symptoms
• Headache
• Stiff neck
• Irritability
• Malaise
• Restlessness
• Nausea vomiting
• Delirium
• Elevated temperature, pulse, respirations
• Kernigs Sign
• inability to extend the legs completely without
  extreme pain
• Brudzinskis Sign
• flexion of the hip and knee when the neck is
  flexed

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Meningitis

• Treatment
• Antibiotics
• massive doses
• multiple types
• IV or intrathecal
• Steroids
• Anticonvulsants
• Dark, quiet room
• stimulation may cause seizure

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Intracranial Tumors

• Etiology/Pathophysiology
• Benign or malignant
• Primary or metastatic
• May affect any area of the brain

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Intracranial Tumors

• Signs Symptoms
• Headache
• Hearing loss
• Motor weakness
• Ataxia
• Decreased alertness and consciousness
• Abnormal pupil response and/or unequal size
• Seizures
• Speech abnormalities

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Intracranial Tumors

• Treatment
• Surgical removal of tumor
• craniotomy
• intracranial endoscopy
• Radiation
• Chemotherapy
• Combination of above

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Crainiotomy
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Craniocerebral Trauma(Head Injury)

• Etiology/Pathophysiology
• Motor vehicle and motorcycle accidents, falls,
  industrial accidents, assaults, and sports trauma
• Direct trauma
• head is directly injured
• acceleration-deceleration injury
• bruising or contusion of the occipital and
  frontal lobes and brainstem and cerebellum
• Indirect trauma
• Tension strains and shearing forces transmitted
  to the head by stretching of the neck

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Craniocerebral Trauma(Head Injury)

• Open head injuries
• Skull fractures
• Penetrating wounds
• Closed head injuries
• Concussions
• violent jarring of the brain against the skull
• Contusions
• Lacerations
• Hematomas
• scalp, epidural, subdural, intracerebral, and
  intraventricular
• epidural and subdural must be monitored carefully

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Craniocerebral Trauma(Head Injury)

• Signs Symptoms
• Headache
• Nausea
• Vomiting
• Abnormal sensations
• Loss of consciousness
• Bleeding from ears or nose
• Abnormal pupil size and\or reaction
• Battles Sign
• in small hemorrhagic spot behind the ear
• may indicate a fracture the lower skull

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Craniocerebral Trauma(Head Injury)

• Treatment
• Maintain airway
• Oxygen
• Mannitol and dexamethasone
• reduce cerebral edema and IICP
• Analgesics
• must not suppress respiratory system
• Anticonvulsants

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Spinal Cord Trauma

• Etiology/Pathophysiology
• Automobile, motorcycle, diving, surfing, other
  athletic accidents, and gunshot wounds
• Fracture of vertebra
• simple, compressed, wedged, comminuted or burst
  fractures
• dislocation of vertebrae
• Complete cord injury
• total transection of the spinal cord
• complete loss of spinal cord function
• Incomplete cord injury
• partial transection or injury of spinal cord

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Spinal Cord Trauma

• Signs Symptoms
• Loss of muscle function depends on level of
  injury
• INJURY LOST FUNCTION
• Above C4 All, including respiration
• C5 Arms, chest, all below chest
• C6-C7 Some arm, fingers, chest, all below
  chest
• Thoracic Trunk, all below chest
• Lumbosacral Legs

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Spinal Cord Trauma

• Spinal Shock
• Vasodilation, increased venous capacity, and
  hypotension
• Autonomic dysreflexia
• Increased reflex actions
• bradycardia, hypertension, diaphoresis, goose
  bumps, severe headache, and nasal stuffiness
• Occurs in injuries above T6 most common in
  cervical injuries
• Result of abnormal cardivascular response to
  stimulation of the sympathetic division of the
  autonomic nervous system
• Occurs as a result of stimulation of the bladder,
  large intestine or other visceral organs

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Spinal Cord Trauma

• Sexual Dysfunction
• Male
• Impotence
• Decreased sensation
• Difficulties with ejaculation
• Infertility
• Female
• Altered sexual pleasure

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Spinal Cord Trauma

• Treatment
• Realignment of bony column for fractures or
  dislocations
• Immobilization
• Skeletal traction
• Crutchfield tongs
• Halo traction
• Stryker frame
• Sugery for spinal decompression
• Methylprednisolone
• high doses

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Spinal Cord Trauma

• Mobility
• Slowly increase sitting up
• may have to use thromboembolism stockings
• prevents hypotension
• Urinary function
• Foley catheter, initially
• Bladder training
• Intermittent catheterization
• Bowel function
• Bowel program
• Dulcolax suppositories
• Digital stimulation
• Adequate fluids
• Stool softeners