NURSE-UN 1243 Adult and Elder Nursing 3 WEEK 2 Exam 1– Neuro Basics &the 3Ds,100% CORRECT

NURSE-UN 1243 Adult and Elder Nursing 3 WEEK 2 Exam 1– Neuro Basics &the 3Ds Changes in the Aging Brain • Changes can occur, especially to the prefrontal cortex and the hippocampus • Changes also occur in neurons, neurotransmitters and blood vessels • Damage from free radicals and inflammation increases • Memory loss is NOT a normal part of the aging process. • Growing evidence of the older brain having adaptive capacities When/How to Assess Cognitive Function When to assess: • On admission/transfer/discharge • Once a shift during hospitalization • As a follow up to hospitalization within 6 weeks • Before making an important healthcare decision • Following changes in pharmacotherapy • During a change in behaviour How to assess: • Mini mental status exam • Mini COG o Give patient 3 words o Have them draw a clock w/ numbers & times o Ask patient to repeat 3 words Dementia • Chronic & terminal illness • You have a change in mental ability enough to interfere w/ daily functioning • Must have memory loss AND another cognitive decline o Loss of coherent speech, ability to understand spoken or written language o Loss of ability to recognize or identify objects o Loss of ability to execute motor activities o Loss of ability to think abstractly, make sound judgments, plan & carry out complex tasks Categories of dementia • Dementia itself is not a diagnosis  it is an umbrella term o Alzheimer’s disease: amyloid plaques develop between nerve cells. 60% of dementia diagnoses = Alzheimer’s. o Lewy body disease: deposits of protein alpha-synuclein in the brain o Vascular dementia: caused by damage due to major stroke or multiple minor stroke o Frontotemporal: progressive nerve cell loss in the frontal lobes o Normal pressure hydrocephalus: accumulation of CSF Mild Cognitive Impairment • Often a prodromal stage of dementia • Independent in ADLs but with a decrease in performance • MCI + depression = much higher likelihood of developing Alzheimer’s disease Alzheimer’s Disease • MOST expensive condition in the nation • Risk factors include: age, family history, head trauma, diabetes, depression, higher education, large social networks • Pathophysiology: development of plaques between neurons  loss of connection and death of neurons Warning Signs of Alzheimer’s • Memory loss that disrupts daily life • Challenges in problem solving • Difficulty completing familiar tasks • Confusion with time or place • Trouble understanding visual images • New problems w/ words • Misplacing things • Decreased/poor judgement • Social withdrawal • Changes in mood/personality • Inability to manage a budget Behavioural Symptoms • Psychomotor agitation  wandering, not being able to sit still • Psychosis  hallucinations, delusions • Aggression  verbal or physical • Apathy  not wanting to do anything all of a sudden • Depression • Sleep  daytime sleepiness, sundowning (keep them awake during the day) Stages of Alzheimer’s 1. Mild AD • Forgetfulness • Word finding difficulty • Apathy • Poor attention • Difficulty w/ complex tasks • Depression • Work trouble 2. Moderate AD • Disorientation • Increasing memory loss • Insomnia • Wandering • Speech difficulty • Restlessness • Difficulty w/ IADLs 3. Severe AD • Agnosia (can’t identify things in hand) • Apraxia (can’t move tongue to speak) • Aggression • Agitation • Incontinence • Poor ADL function • Gait disturbances IADLs • Cooking • Cleaning • Taking medication • Laundry • Shopping • Personal finances • Communication • Transportation ADLs • Eating • Bathing • Dressing • Toileting • Transferring • Continence Management of Alzheimer’s/Dementia • Psychomotor agitation  manage surroundings, address underlying issues, prioritize safety, should not be driving • Psychosis  evaluate meds, optimize sensory deficits • Aggression  cognitive therapies, effective communication techniques • Apathy  activity therapy • Depression  therapy, behavioural interventions, meds if indicated • Meal time issues  redirecting • Sleep  Daytime activities to realign sleep schedule Medication Management • KEY: start with one, start simply • Main medications listed below but can also use the following: o Halperidol for psychotic symptoms o Atypical antipsychotics o Benzodiazepines for agitation and aggression Acetylcholinesterase Inhibitors • Prevents breakdown of acetylcholine • We want to titrate and increase slowly to avoid side effects (NVD, abdominal pain, jaundice, decreased HR, dizziness, headache) • MAJOR a/e = bradycardia and heart block (d/t cholinergic crisis) Memantine • NMDA receptor blocker  blocks excess glutamate (excitatory NT), which can reduce sx associated w/ alzheimers • Can cause dizziness, constipation and headache Delirium 1. Disturbances in attention: reduced ability to direct, focus, sustain, shift attention 2. Disturbances develop over a short period of time 3. Change in an additional cognitive domain  memory deficit, disorientation, language disturbance, perceptual disturbance 4. Changes in 1/3 must not occur because of a coma or severe change in state of arousal Causes of Delirium • D = dementia, dehydration, drugs • E = electrolyte imbalances, emotional stress, encephalopathy • L = lung, liver, low oxygen, low vision/hearing • I = infection, ICU • R = Rx drugs, retention (urine/stool) • I = injury, immobility, intake changes • U = untreated pain, unfamiliar environment, uremia • M = metabolic disorders Assessing Delirium • Confusion assessment method (CAM) (must have 1, 2 and either (3 or 4)) 1. Acute onset or fluctuating course 2. Inattention 3. AND Disorganized thinking or altered level of consciousness Nursing Management of Delirium • Provide orientation • Provide appropriate sensory stimulation • Facilitate sleep • Foster familiarity (have stuff from home) • Maximize mobility & avoid restraints (should be up 2 days after surgery) • Communicate clearly, provide explanations, short, simple, direct • Reassure & educate • Minimize invasive interventions (ie: blood draws)  can increase agitation • Consider psychotropic medications as last resort for agitation Depression • Most common mental disorder • Assess using geriatric depression scale (5 = fine, 5-10 = assess, 10 = most likely depressed) • Assess using PHQ-2 • Symptoms o Depressed mood o Suicidal thoughts (high mortality, men aged 75-85 at greatest risk, often a direct relationship between depression, suicide and alcoholism) Treatment of Depression • SSRIs  block reuptake of serotonin • SNRIs  block reuptake of serotonin and norepinephrine • TCA related medications  Ease depression by affecting naturally occurring chemical messengers (neurotransmitters), which are used to communicate between brain cells • CBT • Electroconvulsion therapy Nursing Interventions • Safety precautions for suicide risk as per institution • Remove/control etiologic agents • Monitor/promote nutrition, elimination, sleep/rest patterns, physical comfort (pain control) • Enhance physical function • Enhance family/social/spiritual support • Maximize autonomy/personal control/self-efficacy • Remove catheters after surgery • Education about medications Neuro Basics • Normal ICP = between 5-15 mmHg • Earliest sign of increasing ICP is a change in consciousness  other signs = papilledema, slurring of speech, delay in response, vomiting • Late indicators of increasing ICP  further decrease in LOC, Cushing’s triad, pupil changes, altered respiratory patterns, posturing WEEK 3 Stroke B = balance E = eyes (blurred vision) F = facial dropping A = arm or leg weakness S = speech difficulty T = time to call for an ambulance! • Stroke can either be an ischemia to part of the brain or a hemorrhage to part of the brain • Damage will correlate to extent of stroke and part of brain affected Non-modifiable risk factors • Age (stroke risk doubles after the age of 55) • Gender (more common in men, more women die) • Ethnicity/race (higher incidence and death rate in blacks) • Hereditary/family history • Prior stroke/TIA Transient Ischemic Attack • Transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, but without acute infarction to the brain • Symptoms typically last less than 1 hour • No way to predict outcome o 1/3 have no additional stroke events o 1/3 have an additional stroke o 1/3 have additional TIAs Types of Stroke • Ischemic stroke: caused by embolism, infarction and thrombosis o Thrombotic: injury to blood vessel wall that results in the formation of a clot, results in narrowing of blood vessel o Embolic: occurs when an embolus lodges in and occludes a cerebral artery • Hemorrhagic stroke: bleeding into the parenchym o Intracerebral or intraparachymal hemmoragh ▪ Sudden onset of symptoms ▪ Poor prognosis (30 day mortality rate of 40-80%) ▪ HTN is most common cause ▪ Tends to occur during activity o Subarachnoid space/ventricles ▪ Most often caused by cerebral aneurysm, trauma or drug abuse ▪ Majority occur in circle of willis ▪ Incidence higher in women ▪ Survivors tend to have many long term consequences Nursing Assessment • Focus first on cardiac, respiratory and neurological assessments • If patient is stable, obtain the following details: o Description of current illness (onset, duration, nature, changes) o History of similar symptoms experienced o Current medications o Risk factors o Family history • Secondary assessment can include a comprehensive neurological examination  NIH stroke scale (must be certified to administer) • Common mistakes include: failure to adequately stimulate patient, failure to check BG, failure to get baseline, failure to recognize subtle clues, too quick Clinical Manifestations of Stroke • Impairment in motor function o Mobility o Respiratory function o Swallowing and speech o Gag reflex o Self-care abilities loss and loss of skill voluntary movement (akenesia) o Impairment of integration of movements o Changes in muscle tone o Altered reflexes o Receptive aphasia = loss of comprehension o Expressive aphasia = loss of production of language o Global aphasia = total loss of ability to communicate o Dysarthia = problems with muscular control of speech Nursing Care Respiratory System • Risk for atelectasis, aspiration pneumonia, airway obstruction • May require endotracheal intubation and mechanical ventilation • Monitor for crackles and wheezes Cardiovascular System • Monitor vital signs frequently • Monitor cardiac rhythms & heart sounds for murmurs • Calculate intake and outputs  adjust fluid intake to meet demands of specific patient • Be careful of orthostatic hypotension before ambulating the patient • After stroke, patient is at risk for venous thromboembolism  weak/paralyzed lower extremities are particularly vulnerable d/t immobility and loss of venous tone. Keep patient moving!! Neurological System • Monitor closely to detect signs suggesting extension of stroke, vasospasm, recovery from stroke symptoms Additional • Monitor GI system for constipation • Integumentary system for skin breakdown • Urinary system for incontinence/bladder retraining Nutritional Needs • Must do a quick assessment to organize treatment for nutritional needs • May need IV nutrition to maintain fluid and electrolyte balance • First feeding should be done very carefully  test gag reflex, pocketing, swallowing • Feedings MUST be followed by scrupulous oral hygiene Communication • Decrease environmental stimuli • Treat patient as an adult • Speak with normal volume and tone • Present one thought or idea at a time • Keep it simple • Do not rush person • Do not pretend to understand • Allow body contact as much as possible • Do not push if person is tired or upset as aphasia worsens with fatigue and anxiety Stroke Collaborative Management • Emergent management: ABCs, prevention of stroke extension, assess level of consciousness (Glasgow Coma Scale), ICP, blood sugar, early intervention with TPA • Endovascular intervention: TPA (must be given within 3-4.5 hours of last known normal period), only for ischemic strokes!! • Medications: can also give aspirin, antihypertensives, steroids, anti-epileptics • Glasgow coma scale (3 = deep coma/brain dead, 15 = fully awake) Intracranial Pressure • Normal ICP is between 5-15 mm Hg • The earliest sign of a change in ICP is a change in level of consciousness • Early indicators in a change of ICP o Papilledema o Slurred speech o Delay in response o Vomiting • Late indicators in a change of ICP o Further decrease in LOC o Cushing’s triad (increase SBP with widening pulse pressure, bradycardia, altered respirations) o Pupil changes o Altered respiratory patterns o Posturing Parkinson’s Disease • Complex interplay between environmental factors and family history • Characterized by o Bradykinesia o Rigidity (cogwheel rigidity) o Tremor at rest o Gait changes (postural instability  disturbed gait and leaning forward) • Idiopathic PD, no identifiable cause & insidious onset • Acquired PD, caused by infection, drug toxicity (if d/t drug toxicity it progresses rapidly), trauma • Dx: no specific disease markers, sometimes dx by how well the pt responds to medication  MRI/CT can be used to rule out other conditions to narrow down to parkinsons Pathophysiology • Lack of dopamine (DA) • Degeneration of dopamine producing neurons in the substantia nigra of the midbrain  disruption of dopamine-acetylcholine in the basal ganglia  disrupts normal functioning of extrapyramidal motor system PD Assessment and Diagnosis • Neuropsych sx: depression, personality changes, psychosis, hallucinations • Autonomic dysfunction: orthostatic hypotension, diaphoresis, drooling, weight loss, urinary sx • Neuromuscular: camptocormia, festination, gait freezing, hyphonia, monotonic speech, festinating speech, dysphagia, hypomimia, micrographia, akathisia • Sleep disturbances: vivid dreams, insomnia, daytime drowsiness PD Collaborative MGMT • Levodopa o Effective but benefits decrease w/ time o Long term use carries risk of dyskinesias o Can be used w/ drugs to assist such as: carbidopa, COMT inhibitors, MOA-B inhibitors • Dopamine receptor agonists o Less effective o Less likely to cause dyskinesias o Can cause troubling side effects • Surgical/electrical tx • Diet: monitor ability of patient to chew and swallow, collaborate with dietician, cut food into small bite sized pieces, eat 6 small meals a day, limit protein intake to evening meal • Exercise: collaborate w/ PT to develop safe exercise intervention • Psychosocial: assess for depression, anxiety and insomnia • Daily living: allow pt to perform ADLs (toileting, transferring, ambulating, bathing, continence, eating) Normal Pressure Hydrocephalus • Accumulation of CSF causing the ventricle of the brain to enlarge • Unknown cause  associated w/ gait disturbance, dementia, urinary incontinence • Tx: shunt WEEK 4 – Neurological & vascular problems Why are older adults at an increased risk of hematomas? 1. Dura matter becomes more adherent, brain weight decreases, reaction times slow 2. Many adults take anticoagulants/aspirin Primary Head Injury vs Secondary Head Injury Primary • Occurs on IMPACT, is a direct result of the impact • Ex: contusions, hematomas, shearing injuries, diffuse white matter injuries, brain lacerations Secondary • Follows the original event and further contributes to the brain injury • Ex: hypoxia, Hypercapnia, systemic hypertension, intracranial hypertension, ischemia, age, PMH • What can help? Hypertonic saline  aids in preventing secondary injury Concussion • Sudden transient mechanical head injury  causes disruption of neural activity and a change in LOC • Post concussion syndrome: persistent headache, lethargy, behaviour changes, changes in intellectual ability, short attention span, decreased short term memory Contusion • Bruising of the brain w/ a focal area • Associated w/ a closed-head injury • Can cause hemorrhage, necrosis, edema, infection • Monitor for seizures Diffuse Axonal Injury • Widespread axonal injury that results from the brain rapidly shifting inside of the skull • The axons are sheared  permanent death of the brain cell • Causes decreased level of consciousness, increased intracranial pressure, global cerebral edema Linear Skull Fracture • Minor traumatic injury • Diagnosed by CT • Non-life threatening, will heal on its own Depressed Skull Fracture • May be visible and palpable, can tear meninges of brain and extend into the tissue • Requires surgical repair of fracture and meninges • May need to evacuate the hematoma • Nursing focus? Pain management of neurological assessment Open/Compound Skull Fracture • Depressed skull fracture with scalp laceration • Risk of infection!! • Nursing focus should be on pain management, neurological assessment and preventing infection Basilar Skull Fracture • Fracture of one of the bones that make up the skull • Assessment findings will probably include: o Periorbital ecchymosis o Mastoid ecchymosis o Facial nerve paralysis o Otorrhea leakage of CSF from ear o Rinnorhea leakage of CSF from nose Nursing/Medical Intervention • Determine if glucose is present in leakage. You will see the halo/ring sing if CSF is present (red  yellow). • Allow CSF to drain and dura to heal on its own. If it does not heal in 1-2 weeks it may require surgical intervention. • Nursing interventions: o Neurological assessment o Pain assessment o Monitor for infection o Change dressings with aseptic technique o Use cotton to absorb CSF leak o Raise HOB • Do not use nasograstric tube for basilar skull fracture Closed Head Injuries • Cerebral hematoma is an accumulation of blood in the skull. It occurs as result of an injury to a cerebral vein or artery. Subdural Hematoma ACUTE • Occurs 48 hours of an injury • Often associated with sudden deceleration or in patients on anticoagulants who have a contusion • Sx: drowsiness, headache, confusion, slowed thinking, agitation SUBACUTE • 48 hrs-2 weeks post-injurt • Neurological deterioration does not occur immediately CHRONIC • Occurs more than 2 weeks post-injury • Often results from a low-impact injury • Sx: headache, lethargy, vomiting, seizures, pupil changes & hemiparesis Management • Drain the hematoma • Frequently reassess LOC (nursing intervention) Complications of a Closed Head Injury • Diabetes insipidus: causes improper water balance  pressure on pituitary causes loss of ADH secretion  large amounts of dilute urine is excreted. GIVE VASOPRESSIN. • SIADH: excess secretions of ADH  increased ICP. Restrict fluids, monitor I&Os, neurological assessments key. • Herniation • Seizures Pupillary Assessment • Pupils equal and react normally • Pupils react to light • One pupil dilates  compression of cranial nerve III • Bilateral dilated, fixed pupils  ominous signs • Bilateral pinpoint pupils  pons damage or drugs Decorticate Posturing • Sign of severe brain injury • Damage to midbrain Decebrate Posturing • Sign of very severe brain injury Decorticate & Decebrate Posturing Opisthonic Posturing Additional Diagnostic Studies • CT scan: best way to diagnose craniocerebral trauma • MRI, PET • Transcranial Doppler • X-Ray • Glasgow Coma Scale (3-8, severe/9-12, moderate/13-15, mild) Emergency Treatment • 8 = intubate • Patent airway • Stabilizer cervical spine • Maintain patient warmth • Monitor • Anticipate intubation • Assume neck injury • Give fluids cautiously • Remove clothing • Obtain IV access • Control bleeding Nursing Diagnosis/Planning • Risk for ineffective cerebral tissue perfusion • Hyperthermia • Impaired physical mobility • Anxiety • Increased ICP Nursing Interventions • Eye drops, compresses, patch • Hyperthermia: goal 36-37 degrees • Prevent shivering • Elevate HOB • Loose collection pad under nose/over ear • NO sneezing, blowing nose • NO NG tube • NO nasotracheal suctioning Epilepsy • Seizures: cluster of nerve cells in the brain signal abnormally  transient, uncontrolled electrical discharge of neurons in the brain o Possible causes include: alcohol withdrawal, acidosis, electrolyte imbalance, hypoglycemia, hypoxemia, dehydration or water intoxication • Epilepsy: a person has had at least two seizures that were not caused by a known medical condition (UNPROVOKED) o Secondary/provoked seizures may occur d/t: brain tumour, metabolic disorder, alcohol withdrawal, electrolyte imbalance, high fever, stroke, head injury, substance use, heart disease Four Stages of a Seizure 1. Prodromal 2. Aural 3. Ictal 4. Post-ictal Types of Seizure FOCAL ONSET • Focal-aware seizure: used to be called partial seizure, the person experiencing the seizure is conscious and will know something is happening/remember the seizure • Focal-impaired awareness seizure: used to be called complex partial seizure  consciousness affected, may be confused, can hear but not fully understand GENERALIZED ONSET • Affects both sides of the brain at once and happens without warning • Tonic-clonic seizure: classic seizure  jerk motions • Atonic seizure: person goes flaccid  falls toward • Tonic seizure: muscles become stiff  fall backwards ADDITIONAL TYPES • Myoclonic: muscle jerks, not associated w/ epilepsy  people have them as they fall asleep • Absence seizures: used to be called petite-mal seizures, person becomes blank and unresponsive for a few seconds • Unknown onset: occurs when the beginning of the seizure is unknown • Non motor seizure: behavioural arrest Seizure Assessments/Interventions • Collect data on history of seizures/current seizure o Important to note which body part the seizure started with o Changes in pupil size or eye deviation o Changes in LOC o Cyanosis, apnea, salivation o Incontinence o Tongue or lip biting o When seizure ended • Reinforce medication compliance • Emphasize safety issues o Place patient on side o Use padded bed rails o Pillow under head o Bed in lowest position o Side rails up o Stay with patient o Monitor for status epilepticus  can give Ativan/Diazepam Seizure Medications • Work to decrease start or decrease spread • AEDs are the most commonly used drugs  gabapentin, keppra, tiagabine, topirmate, lamotrigine Seizure Complications • Status epilepticus: state of continuous seizure activity (5 minutes) o Causes brain to use more energy than supplied o Permanent brain damage can result Vascular Disorders HTN Management • Restrict sodium to 1500 mg/d or 1000 mg/d • Reduce body weight • Reduce alcohol intake (1 drink per day for women, 2 drinks per day for men) • Exercise • Decrease stress levels • Don’t smoke Peripheral Arterial Disease • Progressive thickening of the arteries with fatty deposits  causes degeneration of arteries • Femoral-popliteal artery is most common site in non-diabetics • In diabetics, most common site is distal arteries below the knees • Sx: intermittent claudation, decreased/absent peripheral pulses, loss of hair on arms, feet, legs, ulceration or gangrene of toes and feet, nails thickened/brittle 1. Stage 1 = asymptomatic 2. Stage 2 = claudation 3. Stage 3 = rest pain 4. Stage 4 = necrosis, gangrene, ulcers Ankle-Brachial Index • Divide ankle SBP/brachial SBP • 1-1.3 = normal • 0.90 = venous disease • 0.90 = arterial disease • 0.90-0.71 = mild arterial disease • 0.70-0.40 = moderate arterial disease • 0.40 = severe arterial disease Venous Stasis Ulcer • Incompetent valves of deep veins, usually caused by prolonged HTN • Brown, leathery skin • Ulcers develop at the ankle, above the malleolus • Elevate extremities, extrinsic compression, wound care, observe for infection