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210 Cards in this Set

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For optimal brain functioning what is needed and if interrupted like in cardiac arrest what is the result for brain tissue.
20% of the cardiac output, for optimal brain functioning.
- neurologic metabolism is altered in 30 seconds, metabolism stops in 2 minutes, and cellular death occurs in 5 minutes.
What can increase cerabral blood flow
CO2 is a potent cerebral vasodilator, (increased CO2 levels increase cerebral blood flow and vice versa). Very low arterial O2 levels (partial pressure of arterial O2 ≤50 mm Hg) or an increase in hydrogen ion concentration also increase cerebral blood flow.
What is cerebral autoregulation
This involves changes in the diameter of cerebral blood vessels in response to changes in pressure
-The brain is normally well protected from changes in mean systemic arterial BP over a range from 50 to 150 mm Hg
Atherosclerosis (hardening and thickening of arteries) is a major cause of
stroke. It can lead to thrombus formation and contribute to emboli.
penumbra,
Around the core area of ischemia is a border zone of reduced blood flow called the penumbra,where ischemia is potentially reversible. If adequate blood flow can be restored early (e.g., within 3 hours) and the ischemic cascade can be interrupted,
A thrombotic stroke
formation of a blood clot, is the most common cause of stroke, accounting for about 60% of strokes.15 Two thirds of thrombotic strokes are associated with hypertension or diabetes mellitus, both of which accelerate atherosclerosis. In 30% to 50% of individuals, thrombotic strokes have been preceded by a TIA.
An ischemic stroke
results from inadequate blood flow to the brain from partial or complete occlusion of an artery; these account for approximately 80% of all strokes.14 Ischemic strokes are further divided into thrombotic and embolic.
A lacunar strok
refers to a stroke from occlusion of a small penetrating artery with development of a cavity in the place of the infarcted brain tissue. This most commonly occurs in the basal ganglia, thalamus, internal capsule, or pons. Although a large percentage of lacunar strokes are asymptomatic, when present, symptoms can cause considerable deficits.
rapidity of onset, the size of the lesion, and the presence of collateral circulation
Three things that determine the extent of a stroke
Embolic stroke
Embolism is the second most common cause of stroke, accounting for about 24% of strokes.15 The majority of emboli originate in the endocardial (inside) layer of the heart, with plaque breaking off from the endocardium and entering the circulation.occurs when an embolus lodges in and occludes a cerebral artery, resulting in infarction and edema
Hemorrhagic strokes
account for approximately 15% of all strokes and result from bleeding into the brain tissue itself
Intracerebral hemorrhag
Hypertension is the most important cause of intracerebral hemorrhage
Hemorrhage in the pons is the most serious because
basic life functions (e.g., respiration) are rapidly affected. Hemorrhage in the pons can be characterized by hemiplegia leading to complete paralysis, coma, abnormal body posturing, fixed pupils, hyperthermia, and death.18
Subarachnoid hemorrhage
intracranial bleeding into the cerebrospinal fluid–filled space between the arachnoid and pia mater membranes on the surface of the brain. Subarachnoid hemorrhage is commonly caused by rupture of a cerebral aneurysm
The characteristic presentation of a ruptured aneurysm in the brain is the sudden onset of
a severe headache that is different from a previous headache and typically the “worst headache of one's life.” Loss of consciousness may or may not occur
A stroke can have an effect on many body functions, including
motor activity, bladder and bowel elimination, intellectual function, spatial-perceptual alterations, personality, affect, sensation, swallowing, and communication
Clinical Manifestations of a stroke
-The left hemisphere is dominant for language skills in right-handed persons and in most left-handed persons.
-Patients who have had a stroke may have difficulty controlling their emotions.
-Both memory and judgment may be impaired as a result of stroke.
-A stroke on the right side of the brain is more likely to cause problems in spatial-perceptual orientation
-When a stroke affects one hemisphere of the brain, the prognosis for normal bladder function is excellent.
-
Diagnostic Studies
single most important diagnostic tool for patients who have experienced a stroke is the noncontrast CT scan.21 The CT scan should optimally be obtained within 25 minutes and read within 45 minutes of arrival at the emergency department.
- If the stroke is less than 3 hours old and is ischemic in nature, the CT will appear normal because the brain structures with or without blood flow appear the same in a noncontrast CT scan.
-Magnetic resonance imaging (MRI) is used to determine the extent of brain injury. MRI has greater specificity compared with CT.
-Angiography is the “gold standard” for imaging the carotid arteries. Angiography can identify cervical and cerebrovascular occlusion, atherosclerotic plaques, and malformation of vessels.
-PET shows the metabolic activity of the brain and provides a depiction of the extent of tissue damage after a stroke. Less active or diseased tissue appears darker than healthy, active cells. MRS detects biochemical changes that may be present before physical changes are apparent.
-Transcranial Doppler (TCD) ultrasonography is a noninvasive study that measures the velocity of blood flow in the major cerebral arteries.
-A lumbar puncture may be done to look for evidence of red blood cells in the cerebrospinal fluid if a subarachnoid hemorrhage is suspected but the CT does not show hemorrhage.
priority for decreasing morbidity and mortality from stroke
Health promotion focuses on (1) healthy diet, (2) weight control, (3) regular exercise, (4) no smoking, (5) limiting alcohol consumption, and (6) routine health assessments. Patients with known risk factors such as diabetes mellitus, hypertension, obesity, high serum lipids, or cardiac dysfunction require close management.
-endarterectomy
, A tube is inserted above and below the blockage to reroute the blood flow. B, Atherosclerotic plaque in the common carotid artery is removed. C, Once the artery is stitched closed, the tube can be removed. A surgeon may also perform the technique without rerouting the blood flow.
Stroke assessment findings
Altered level of consciousness

• Weakness, numbness, or paralysis of portion of body

• Speech or visual disturbances

• Severe headache

• Heart rate ↑ or ↓

• Respiratory distress

• Unequal pupils

• Hypertension

• Facial drooping on affected side

• Difficulty swallowing

• Seizures

• Bladder or bowel incontinence

• Nausea and vomiting

• Vertigo
The goals for collaborative care during the acute phase are
preserving life, preventing further brain damage, and reducing disability. Treatment differs according to the type of stroke and changes as the patient progresses from the acute to the rehabilitation phase.
Stroke interventions
Ensure patent airway.

• Call a stroke code or the stroke team.

• Remove dentures.

• Perform pulse oximetry.

• Maintain adequate oxygenation (SaO2 >92%) with supplemental O2, if necessary.

• Establish IV access with normal saline.

• Maintain BP according to guidelines (e.g., Cardiac Life Support).*

• Remove clothing.

• Obtain CT scan immediately.

• Perform baseline laboratory tests (including blood glucose) immediately, and treat if hypoglycemic.

• Position head midline.

• Elevate head of bed 30 degrees if no symptoms of shock or injury.

• Institute seizure precautions.

• Anticipate thrombolytic therapy for ischemic stroke.

Ongoing Monitoring

• Monitor vital signs and neurologic status, including level of consciousness (Glasgow Coma Scale), motor and sensory function, pupil size and reactivity, SaO2, and cardiac rhythm.

• Reassure patient and family.
tPA must be administered within
3 hours of the onset of clinical signs of ischemic stroke. Therefore the single most important factor is timing. Patients are screened carefully before tPA can be given. Screening includes a noncontrast CT or MRI scan to rule out hemorrhagic stroke, blood tests for coagulation disorders, and screening for recent history of gastrointestinal bleeding, stroke, or head trauma within the past 3 months, or major surgery within 14 days.21
GDC coil.
A coil is used to occlude an aneurysm. Coils are made of soft, springlike platinum. The softness of the platinum allows the coil to assume the shape of irregularly shaped aneurysms while posing little threat of rupture of the aneurysm
The Merci retriever removes
blood clots in patients who are experiencing ischemic strokes. The retriever is a long, thin wire that is threaded through a catheter into the femoral artery.
After the stroke patient has stabilized for 12 to 24 hours, collaborative care shifts from preserving life to
lessening disability and attaining optimal function.
The goals for rehabilitation of the patient with stroke are mutually set by the patient, family, nurse, and other members
Learn techniques to self-monitor and maintain physical wellness

• Demonstrate self-care skills

• Exhibit problem-solving skills with self-care

• Avoid complications associated with stroke

• Establish and maintain a useful communication system

• Maintain nutritional and hydration status

• List community resources for equipment, supplies, and support

• Establish flexible role behaviors to promote family cohesiveness
Collateral ciruculation
most often determines the extent of cerabral damage from a stroke
a 65-year-old African American man with hypertension.
very high risk for a stroke
Sudden onset of severe headache
most often relates to a hemmorrhagic stroke
What does an angiography do
check the patency of the cerebral blood vessels
CULTURAL AND ETHNIC HEALTH DISPARITIES

Stroke
• African Americans have a higher incidence of strokes than whites.

• The rate of first strokes in African Americans is almost twice that of whites.

• This high incidence may be related to increased rates of hypertension, diabetes mellitus, and sickle cell anemia in African Americans.

• African Americans also have a higher incidence of smoking and obesity than whites, which are two other risk factors for stroke.

• African Americans are twice as likely to die from a stroke as whites.

• Hispanics, Native Americans, and Asian Americans have a higher incidence of strokes than whites.
GENDER DIFFERENCES

Stroke

Men
• Stroke is more common in men than in women

• In most age groups, more men than women will have a stroke in a given year

• More likely to have a thrombotic stroke

• More likely to have an embolic stroke

Have better chance of surviving from a stroke
GENDER DIFFERENCES

Stroke
Women
• At all ages, more women than men die from strokes

• More likely to have a hemorrhagic stroke

• Oral contraceptive use and pregnancy contribute to stroke risk

• tPA used less frequently to treat women who have strokes
Hypertension is the single most important
modifiable risk factor, but it is still often undetected and inadequately treated.4 Increases in systolic and diastolic blood pressure (BP) independently increase the risk of stroke. Stroke risk can be reduced by up to 42% with appropriate treatment of hypertension.1,7
dysarthria,
a disturbance in the muscular control of speech. Impairments may involve pronunciation, articulation, and phonation.
Increased ICP from cerebral edema usually peaks in
72 hours and may cause brain herniation. Management of increased ICP includes practices that improve venous drainage, such as elevating the head of the bed, maintaining head and neck in alignment, and avoiding hip flexion
Hyperthermia, which is seen commonly following stroke and may be associated with poorer outcome, needs to be avoided. Increased temperature contributes to
increased cerebral metabolism. Other measures include pain management, avoidance of hypervolemia, and management of constipation. Cerebrospinal fluid drainage may be used in some patients to reduce ICP. Diuretic drugs, such as mannitol (Osmitrol) and furosemide (Lasix), may be used to decrease cerebral edema. The use of mannitol is being reexamined and compared to hypertonic saline and dextran solution infusions (HSD) for therapeutic treatment of increased ICP. Preliminary findings indicate that HSD is as effective as mannitol in lowering ICP.28 As a last resort in the management of ICP, a bone flap may be removed to allow for cerebral edema without increases in ICP. The bone flap is frozen and replaced later.29
IV solutions with glucose and water are avoided because
they are hypotonic and may further increase cerebral edema and ICP. In addition, hyperglycemia may be associated with further brain damage and should be treated.
Cerebral Perfusion Promotion
• Monitor neurologic status to detect changes indicative of worsening or improving condition.

• Monitor respiratory status (e.g., rate, rhythm, and depth of respirations; PaO2, PaCO2, pH, and bicarbonate levels) to assess changes in neurologic status.

• Monitor patient's ICP and neurologic responses to care activities as ICP can increase with changes in positioning and movement.

• Administer vasopressin, calcium channel blockers, anticoagulant medications, antiplatelet medications, thrombolytic medications (as ordered) to increase tissue perfusion.

• Administer volume expanders (as ordered) to maintain hemodynamic parameters.

• Avoid neck flexion or extreme hip/knee flexion to avoid obstruction of arterial and venous blood flow.
Nursing Diagnosis

Ineffective airway clearance related to inability to raise secretions as evidenced by adventitious breath sounds, diminished breath sounds, and ineffective cough

Patient Goal

1. Demonstrates effective coughing and increased air exchange

2. Maintains a clear airway
Airway Management

• Auscultate breath sounds, noting areas of decreased/absent ventilation, and presence of adventitious sounds to obtain ongoing data on patient's response to therapy.

• Remove secretions by encouraging coughing or by suctioning to clear airway.

Cough Enhancement

• Assist patient to a sitting position with head slightly flexed, shoulders relaxed, and knees flexed to provide optimal positioning for generating maximum intrathoracic pressure during cough.

• Instruct patient to inhale deeply, bend forward slightly, and perform three or four huffs (against an open glottis) to expel secretions.

• Encourage use of incentive spirometry to open collapsed alveoli, promote deep breathing, and prevent atelectasis.
Impaired physical mobility related to neuromuscular and cognitive impairment and decreased muscle strength and control as evidenced by limited ability to perform gross and fine motor skills, limited range of motion, and difficulty turning

Patient Goal

1. Demonstrates increased muscle strength and ability to move

2. Uses adaptive equipment to increase mobility
• Collaborate with physical, occupational, and recreational therapists in developing and executing exercise program to determine extent of problem and plan appropriate interventions.

• Determine patient's readiness to engage in activity or exercise protocol to assess expected level of participation.

• Apply splints to achieve stability of proximal joints involved with fine motor skills to prevent contractures.

• Encourage patient to practice exercises independently to promote patient's sense of control.

• Provide restful environment for patient after periods of exercise to facilitate recuperation.
Nursing Diagnosis

Impaired verbal communication related to residual aphasia as evidenced by refusal or inability to speak, word-finding problems, inappropriate verbalization, inability to follow verbal directions

Patient Goals

1. Uses effective oral and written communication techniques

2. Demonstrates congruency of verbal and nonverbal communication
• Listen attentively to convey the importance of patient's thoughts and to promote a positive environment for learning.

• Provide positive reinforcement and praise to build self-esteem and confidence.

• Use simple words and short sentences to avoid overwhelming patient with verbal stimuli.

• Provide verbal prompts/reminders to assist patient to express self.
Unilateral neglect related to visual field cut and sensory loss on one side of body as evidenced by consistent inattention to stimuli on affected side

Patient Goal

1. Cares for both sides of the body appropriately

2. Uses strategies to minimize unilateral neglect
• Monitor for abnormal responses to three primary types of stimuli: sensory, visual, and auditory to determine the presence of and degree to which unilateral neglect exists (i.e., inability to see objects on affected side, leaving food on a plate that corresponds to affected side, lack of sensation on affected side).

• Instruct patient to scan from left to right to scan the entire environment.

• Rearrange the environment to use the right or left visual field; position personal items, television, or reading materials within view on unaffected side to compensate for visual field deficits.

• Touch unaffected shoulder when initiating conversation to attract patient's attention.

• Position bed in room so that individuals approach and care for patient on unaffected side.

• Gradually move personal items and activity to affected side, as patient demonstrates an ability to compensate for neglect.

• Include family in rehabilitation process to support the patient's efforts and assist with care to promote reintegration with the whole body.
Nursing Diagnosis

Impaired urinary elimination related to impaired impulse to void or inability to reach toilet or manage tasks of voiding as evidenced by incontinence and flow of urine at unpredictable times

Patient Goal

1. Perceives impulse to void, removes clothing for toileting, and uses toilet

2. Demonstrates ability to urinate when the urge arises or with a timed schedule
• Encourage patient to keep a voiding diary to establish voiding pattern and plan appropriate interventions.

• Establish interval of initial toileting schedule, based on voiding pattern to initiate process of improving bladder functioning and increased muscle tone.

• Toilet patient or remind patient to void at prescribed intervals to assist patient in adapting to new toileting schedule.

• Teach patient to consciously hold urine until the scheduled toileting time to improve muscle tone.

• Discuss daily record of continence with patient to provide reinforcement and to allow time to ask questions, make comments, or share concerns.
Nursing Diagnosis

Nursing Diagnosis Impaired swallowing related to weakness or paralysis of affected muscles as evidenced by drooling, difficulty in swallowing, choking

Patient Goals

Demonstrates effective swallowing without choking, coughing, or aspiration
• Collaborate with other members of health care team (i.e., occupational therapist, speech pathologist, and dietitian) to provide continuity in patient's rehabilitative plan.

• Assist patient to sit in an erect position (as close to 90 degrees as possible) for feeding/exercise to provide optimal position for chewing and swallowing without aspirating.

• Assist patient to position head in forward flexion in preparation for swallowing (“chin tuck”).

• Assist patient to maintain sitting position for 30 minutes after completing meal to prevent regurgitation of food.

• Instruct patient/caregiver on emergency measures for choking to prevent complications in the home setting.

• Check mouth for pocketing of food after eating to prevent collection and putrefaction of food and or aspiration.

• Provide mouth care as needed to promote comfort and oral health.

• Monitor body weight to determine adequacy of nutritional intake.
ituational low self-esteem related to actual or perceived loss of function and altered body image as evidenced by refusal to touch or look at affected body parts, refusal to participate in self-care, and expressions of helplessness and uselessness

Patient Goal

1. Expresses positive feelings of self-worth

2. Participates in self-care of affected body parts
Self-Esteem Enhancement

• Monitor patient's statements of self-worth to determine effect of stroke on self-esteem.

• Encourage patient to identify strengths to facilitate patient's recognition of intrinsic value.

• Assist in setting realistic goals to achieve higher self-esteem.

• Reward or praise patient's progress toward reaching goals.

• Encourage increased responsibility for self to promote sense of satisfaction, independence, and control, and to reduce frustrations.

• Monitor levels of self-esteem over time to determine stressors or situations that trigger low self-esteem and to teach coping mechanisms.

Body Image Enhancement

• Monitor whether patient can look at the changed body part to determine patient's level of acceptance of new image.

• Help patient to determine the extent of actual changes in the body or its level of functioning to prevent misperceptions concerning new level of physiologic functioning.
Passive range-of-motion exercise is begun on the
first day of hospitalization.
Muscle atrophy secondary to lack of innervation and activity can develop within
1 month following stroke.
Nursing interventions to optimize musculoskeletal function include (
1) trochanter roll at the hip to prevent external rotation; (2) hand cones (not rolled washcloths) to prevent hand contractures; (3) arm supports with slings and lap boards to prevent shoulder displacement; (4) avoidance of pulling the patient by the arm to avoid shoulder displacement; (5) posterior leg splints, footboards or high-top tennis shoes to prevent footdrop; and (6) hand splints to reduce spasticity.
A bladder retraining program consists of
(1) adequate fluid intake with the majority given between 8:00 am and 7:00 pm; (2) scheduled toileting every 2 hours using bedpan, commode, or bathroom; and (3) noting signs of restlessness, which may indicate the need for urination.
Homonymous hemianopsia
(blindness in the same half of each visual field) is a common problem after a stroke (Fig. 58-11). Persistent disregard of objects in part of the visual field should alert the nurse to this possibility. Initially, the nurse helps the patient to compensate by arranging the environment within the patient's perceptual field, such as arranging the food tray so that all foods are on the right side or the left side to accommodate for field of vision
The paralyzed or weak side needs special attention when the patient is positioned.
Each joint should be positioned higher than the joint proximal to it to prevent dependent edema
The most common response of the stroke patient to the change in body image is
depression.
Cluster Headache
-Unilateral, radiating up or down from one eye
-Severe, bone-crushing
-May have months or years between attacks; attacks occur in clusters: 1-3 times a day over a period of 4-8 wk
-Nocturnal; commonly awakens patient from sleep, lasts 30 to 90 min
-Vasomotor symptoms such as facial flushing or pallor, unilateral lacrimation, ptosis, and rhinitis
Migraine Headache
Unilateral (in 60%), may switch sides, commonly anterior
-Throbbing, synchronous with pulse
-Periodic; cycles of several months to years
-Continuous for hours or days
-May be preceded by prodrome; onset after awakening; gets better with sleep
-Nausea or vomiting; edema; irritability; sweating; photophobia; phonophobia; prodrome of sensory, motor, or psychic phenomena; family history (in 65%)
Tension-Type Headache
Bilateral, bandlike pressure at base of skull, in face, or in both
-Constant, squeezing tightness
-Cycles for several years
-Intermittent for months or years
-Not related to time
-Palpable neck and shoulder muscles, stiff neck, tenderness
GENDER DIFFERENCES

Headaches
MEN
• Migraine headaches affect 6% of men.*

• Cluster headaches are more common in men.

• Exercise-induced headaches are more common in men.
GENDER DIFFERENCES

Headaches
Women
Migraine headaches affect 18% of women.*
Tension-type headache,Diagnosis
the most common type of headache
-Careful history taking is probably the most important tool for diagnosing tension-type headache. Electromyography (EMG) may be performed. This test may reveal sustained contraction of the neck, scalp, or facial muscles
- increased resistance to passive movement of the head and tenderness of the head and neck may be present.
Etiology and Pathophysiology
Migraine headache
The vascular theory suggests that vasoconstriction followed by vasodilation with resulting changes in blood flow causes the throbbing pain. A second theory proposes that the pain is a result of muscular tension, and thus is related to tension-type headache. The third theory relates to biochemical changes, proposing that changes in the serotonin pathway result in the headache pain.
-may be precipitated or triggered by foods, hormonal fluctuation, head trauma, physical exertion, fatigue, stress, and pharmacologic agents. Food triggers include chocolate, cheese, oranges, tomatoes, onions, monosodium glutamate, aspartame, red wine, and alcohol.3
Migraines are subdivided by the IHS into categories. The two most important are
those without aura (formerly called common migraine) and those with aura (formerly called classic migraine). Migraine without aura is the most common type of migraine headache. Migraine with aura occurs in only 10% of migraine headache episodes. The sharply defined aura may last for 10 to 30 minutes before the start of the headache and may include sensory dysfunction (e.g., visual field defects, tingling or burning sensations, paresthesias), motor dysfunction (e.g., weakness, paralysis), dizziness, confusion, and even loss of consciousness.
Cluster headaches
are a rare form of headache, affecting less than 0.1% of the population.4 Cluster headaches involve repeated headaches that can occur for weeks to months at a time, followed by periods of remission.pain of cluster headache is described as sharp and stabbing, The vasodilation that occurs in the affected part of the face is extracranial. The trigeminal nerve is implicated in the production of pain. Cluster headaches involve dysfunction of intracranial blood vessels, the sympathetic nervous system, and pain modulation systems. Due to the circadian rhythmicity of the headaches, the hypothalamus is believed to play a role.
Triptans
are drugs that affect selected serotonin receptors, and treat the primary cause of migraine. These drugs reduce the neurogenic inflammation of the cerebral blood vessels and produce vasoconstriction.
Seizure is
a paroxysmal, uncontrolled electrical discharge of neurons in the brain that interrupts normal function. Seizures are often symptoms of an underlying illness. They may accompany a variety of disorders, or they may occur spontaneously without any apparent cause. Seizures resulting from systemic and metabolic disturbances are not considered epilepsy if the seizures cease when the underlying problem is corrected
metabolic disturbances that cause seizures include
acidosis, electrolyte imbalances, hypoglycemia, hypoxia, alcohol and barbiturate withdrawal, dehydration, and water intoxication. Extracranial disorders that can cause seizures are heart, lung, liver, or kidney diseases; systemic lupus erythematosus; diabetes mellitus; hypertension; and septicemia.
Nursing Diagnosis

Acute pain related to headache as evidenced by complaint of steady, throbbing, or severe crushing pain

Patient Goals

1. Reports satisfaction with pain relief

2. Uses pharmacologic and nonpharmacologic measures appropriately to manage pain
• Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors to determine appropriate interventions.

• Utilize appropriate assessment method that allows for monitoring of change in pain and that will assist in identifying actual and potential precipitating factors (e.g., flowsheet, daily diary) to provide patient some control in identifying and controlling factors that may precipitate headaches.

• Teach the use of nonpharmacologic techniques (e.g., biofeedback, relaxation, guided imagery, music therapy, distraction, and massage) before pain occurs or increases, and along with other pain-relief measures to provide sense of control over pain.

• Provide the person optimal pain relief with prescribed analgesics to reduce pain.

• Evaluate the effectiveness of the pain-control measures used through ongoing assessment of the pain experience to assess efficacy and identify adverse drug effects.

• Consider referrals for patient, family, and significant others to support groups and other resources to reduce stress.
Epilepsy is a condition in which
a person has spontaneously recurring seizures caused by a chronic underlying condition.
-. The incidence rates are high during the first year of life, decline through childhood and adolescence, plateau in middle age, and rise sharply again among the elderly. The population with the highest prevalence of new-onset epilepsy is those over the age of 60.
The most common causes of seizure disorder during the first 6 months of life are
e severe birth injury, congenital defects involving the central nervous system (CNS), infections, and inborn errors of metabolism.
In patients between 2 and 20 years of age, the primary causative factors are
birth injury, infection, trauma, and genetic factors. In individuals between 20 and 30 years of age, seizure disorder usually occurs as the result of structural lesions, such as trauma, brain tumors, or vascular disease.
After 50 years of age the primary causes of seizure disorders are
cerebrovascular lesions and metastatic brain tumors
Although many causes of seizure disorders have been identified, three fourths of all seizure disorder cases cannot be
attributed to a specific cause and are considered idiopathic.
However, there is now evidence that astrocytes, or cerebral support cells
may play a key role in recurring seizures. Astrocytes release glutamate that triggers synchronous firing of neurons. Therefore drug therapy focused on suppressing astrocyte signaling or decreasing glutamate release may be a mechanism to achieve seizure control.14
Generalized seizures involve
both sides of the brain and are characterized by bilateral synchronous epileptic discharges in the brain from the onset of the seizure. Because the entire brain is affected at the onset of the seizures, there is no warning or aura. In most cases, the patient loses consciousness for a few seconds to several minutes.
The most common generalized seizure is the generalized tonic-clonic (formerly known as grand mal) seizure. Tonic-clonic seizure
is characterized by loss of consciousness and falling to the ground if the patient is upright, followed by stiffening of the body (tonic phase) for 10 to 20 seconds and subsequent jerking of the extremities (clonic phase) for another 30 to 40 seconds. Cyanosis, excessive salivation, tongue or cheek biting, and incontinence may accompany the seizure.

In the postictal phase the patient usually has muscle soreness, is very tired, and may sleep for several hours. Some patients may not feel normal for several hours or days after a seizure. The patient has no memory of the seizure.
absence (petit mal) seizure usually occurs only in
children and rarely continues beyond adolescence. This type of seizure may cease altogether as the child matures, or it may evolve into another type of seizure. The typical clinical manifestation is a brief staring spell that lasts only a few seconds, so it often occurs unnoticed. There may be an extremely brief loss of consciousness. When untreated, the seizures may occur up to 100 times a day.
A myoclonic seizure is characterized by
a sudden, excessive jerk of the body or extremities. The jerk may be forceful enough to hurl the person to the ground. These seizures are very brief and may occur in clusters.
Partial seizures are
They are caused by focal irritations. They manifest with unilateral manifestations that arise from localized brain involvement. Partial seizures begin in a specific region of the cortex,
-Any tonic-clonic seizure that is preceded by an aura or warning is a partial seizure that generalizes secondarily.
-Partial seizures may be confined to one side of the brain and remain partial or focal in nature, or they may spread to involve the entire brain, culminating in a generalized tonic-clonic seizure.
Status epilepticus is
a state of continuous seizure activity or a condition in which seizures recur in rapid succession without return to consciousness between seizures. It is the most serious complication of epilepsy and is a neurologic emergency. Status epilepticus can occur due to any type of seizure. During repeated seizures the brain uses more energy than can be supplied. Neurons become exhausted and cease to function. Permanent brain damage may result. Tonic-clonic status epilepticus is the most dangerous because it can cause ventilatory insufficiency, hypoxemia, cardiac dysrhythmias, hyperthermia, and systemic acidosis, all of which can be fatal.
diagnosis of epilepsy or seizure disorder
The most useful diagnostic tools are an accurate and comprehensive description of the seizures and the patient's health history
If a patient is diagnosed with a seizure disorder, it is very important to classify the seizure type correctly (see Fig. 59-1 and Table 59-6). The choice of treatment depends on
the classification of the type of seizure.
Drugs generally act by stabilizing nerve cell membranes and preventing spread of the epileptic discharge. In about 70% of the patients,
seizure disorders are controlled by medication. The primary goal of antiseizure drug therapy is to obtain maximum seizure control with a minimum of toxic side effects
During the seizure it is important to
maintain a patent airway. This may involve supporting and protecting the head, turning the patient to the side, loosening constrictive clothing, or easing the patient to the floor, if seated. The patient should not be restrained, and no objects should be placed in the mouth. After the seizure the patient may require suctioning, and oxygen may be needed.
Because many seizure disorders cannot be cured,
drugs must be taken regularly and continuously, often for a lifetime. The nurse should ensure that the patient knows this, as well as the specifics of the drug regimen and what to do if a dose is missed. Usually the dose should be made up if the omission is remembered within 24 hours
Nursing Diagnosis

Ineffective breathing pattern related to neuromuscular impairment secondary to prolonged tonic phase of seizure or during postictal period as evidenced by abnormal respiratory rate, rhythm, and/or depth

Patient Goals

Experiences breathing pattern adequate to meet oxygen needs
Airway Management

• Monitor respiratory and oxygenation status to determine presence and extent of problem and to initiate appropriate interventions.

• Position patient (side-lying) to maximize ventilation potential.

• Identify patient requiring actual/potential airway insertion to facilitate intubation as necessary.

• Perform endotracheal or nasotracheal suctioning to maintain airway.

Seizure Management

• Loosen clothing to prevent restricted breathing.

• Apply oxygen as appropriate to maintain oxygenation and prevent hypoxia.
Nursing Diagnosis

Risk for injury related to seizure activity and subsequent impaired physical mobility secondary to postictal weakness

Patient Goals

Experiences no seizure-related injury
eizure Precautions

• Monitor compliance in taking antiseizure medications to determine risk for seizures.

• Remove potentially harmful objects from the environment.

• Keep suction, Ambu bag, oral or nasopharyngeal airway at bedside to maintain airway and oxygenation if needed.

• Use padded side rails to prevent injury during a seizure.

Seizure Management

• Remain with patient during seizure to protect patient from injury.

• Guide movements to prevent injury during a seizure.

• Record seizure characteristics: body parts involved, motor activity, and seizure progression.

• Monitor postictal period duration and characteristics to plan appropriate interventions as needed.
Nursing Diagnosis

Ineffective therapeutic regimen management related to lack of knowledge about management of seizure disorder as evidenced by verbalization of lack of knowledge, inaccurate perception of health status, noncompliance with prescribed health behavior

Patient Goal

1. Describes factors involved in effective management of seizure disorder

2. Makes decisions about health and lifestyle modifications necessary for management of seizure disorder
Teaching: Disease Process

• Discuss lifestyle changes (e.g., avoidance of precipitating factors, driving restrictions, wearing medical ID tags, moderation in drinking and eating, exposure to stress, and avoidance of hazardous activities) that may be required to prevent future complications and/or control the disease process.

• Discuss therapy/treatment options and describe rationale behind management/treatment options so patient and family can make lifestyle modifications to manage a chronic disease.
Parkinson's disease (PD)
is a disease of the basal ganglia characterized by slowness in the initiation and execution of movement (bradykinesia), increased muscle tone (rigidity), tremor at rest, and impaired postural reflexes. It is the most common form of parkinsonism (a syndrome characterized by similar symptoms). PD is named after James Parkinson, who, in 1817, wrote a classic essay on “shaking palsy,” a disease whose cause is still unknown.
The prevalence of PD is
about 160 per 100,000 and the incidence is about 20 per 100,000. The diagnosis of PD increases with age, with the peak onset in the 70s. To date, more than 10 autosomal dominant and recessive genes have been linked to familial PD. PD is more common in men by a ratio of
The pathologic process of PD involves
degeneration of the dopamine-producing neurons in the substantia nigra of the midbrain (Figs. 59-5 through 59-7), which in turn disrupts the normal balance between dopamine (DA) and acetylcholine (ACh) in the basal ganglia. DA is a neurotransmitter essential for normal functioning of the extrapyramidal motor system, including control of posture, support, and voluntary motion. Symptoms of PD do not occur until 80% of neurons in the substantia nigra are lost.
The onset of PD is
is gradual and insidious, with a gradual progression and a prolonged course. It may involve only one side of the body initially. The classic manifestations of PD often include tremor, rigidity, and bradykinesia, which are often called the triad of PD. In the beginning stages, only a mild tremor, a slight limp, or a decreased arm swing may be evident. Later in the disease the patient may have a shuffling, propulsive gait with arms flexed and loss of postural reflexes. In some patients there may be a slight change in speech patterns. None of these alone is sufficient evidence for a diagnosis of the disease.
Dopaminergic synaptic activity is mediated by dopamine. Cholinergic synaptic activity is mediated by acetylcholine.
A balance between the two kinds of activity produces normal motor function. A relative excess of cholinergic activity produces akinesia and rigidity. A relative excess of dopaminergic activity produces involuntary movements. Neurons in the caudate nucleus contain g-aminobutyric acid (GABA) and possibly control dopaminergic neurons in the substantia nigra through a feedback pathway
Parkinsonian tremor is more prominent
at rest and is aggravated by emotional stress or increased concentration. The hand tremor is described as “pill rolling” because the thumb and forefinger appear to move in a rotary fashion as if rolling a pill, coin, or other small object. Tremor can involve the diaphragm, tongue, lips, and jaw but rarely causes shaking of the head.
Rigidity, the second sign of the triad, is the increased
resistance to passive motion when the limbs are moved through their range of motion. Parkinsonian rigidity is typified by a jerky quality, as if there were intermittent catches in the movement of a cogwheel, when the joint is moved passively. This is termed cogwheel rigidity. The rigidity is caused by sustained muscle contraction and consequently elicits a complaint of muscle soreness; feeling tired and achy; or pain in the head, upper body, spine, or legs. Another consequence of rigidity is slowness of movement because it inhibits the alternating of contraction and relaxation in opposing muscle groups (e.g., biceps and triceps).
Bradykinesia is particularly evident in the loss of
automatic movements, which is secondary to the physical and chemical alteration of the basal ganglia and related structures in the extrapyramidal portion of the CNS. In the unaffected patient, automatic movements are involuntary and occur subconsciously. They include blinking of the eyelids, swinging of the arms while walking, swallowing of saliva, self-expression with facial and hand movements, and minor movement of postural adjustment,,,,The posture is that of a slowed “old man” image, with the head and trunk bent forward and the legs constantly
In addition to the motor signs of PD, many nonmotor symptoms are common
General debilitation may lead to pneumonia, urinary tract infections, and skin breakdown. Orthostatic hypotension may occur in some patients and, along with loss of postural reflexes, may result in falls or other injury.
diagnostic test for PD
Because there is no specific diagnostic test for PD, the diagnosis is based solely on the history and the clinical features. A firm diagnosis can be made only when at least two of the three characteristic signs of the classic triad are present: tremor, rigidity, and bradykinesia. The ultimate confirmation of PD is a positive response to antiparkinsonian drugs.
Drug therapy for PD is aimed at
Drug therapy for PD is aimed at correcting an imbalance of neurotransmitters within the CNS. Antiparkinsonian drugs either enhance the release or supply of DA (dopaminergic) or antagonize or block the effects of the overactive cholinergic neurons in the striatum (anticholinergic). Levodopa with carbidopa (Sinemet) is often the first drug to be used. Levodopa is a chemical precursor of DA and can cross the blood-brain barrier. It is converted to DA in the basal ganglia. Sinemet is the preferred drug because it also contains carbidopa, an agent that inhibits the enzyme dopa-decarboxylase in the peripheral tissues. Dopa-decarboxylase breaks down levodopa before it reaches the brain. The net result of the combination of levodopa and carbidopa is that more levodopa reaches the brain, and therefore less drug is needed. Carbidopa/levodopa is also available as Paracopa, which is a tablet that rapidly dissolves in the mouth. It can be given with or without water.
Surgical procedures are aimed at relieving symptoms of PD and are usually used in patients who are unresponsive to drug therapy or who have developed severe motor complications. Surgical procedures fall into three categories:
ablation (destruction), deep brain stimulation (DBS), and transplantation.
Diet is of major importance to the patient with PD because
malnutrition and constipation can be serious consequences of inadequate nutrition. Patients who have dysphagia and bradykinesia need appetizing foods that are easily chewed and swallowed. The diet should contain adequate roughage and fruit to avoid constipation.
Amyotrophic lateral sclerosis (ALS) is
a rare progressive neurologic disorder characterized by loss of motor neurons. ALS usually leads to death within 2 to 6 years after diagnosis. The onset is usually between 40 and 70 years of age. ALS is more common in men than women by a ratio of 2:1.
The typical symptoms of ALS are
weakness of the upper extremities, dysarthria, and dysphagia. However, weakness may begin in the legs. Muscle wasting and fasciculations result from the denervation of the muscles and lack of stimulation and use. Death usually results from respiratory infection secondary to compromised respiratory function. Unfortunately, there is no cure for ALS.
Riluzole (Rilutek)
slows the progression of ALS.39 This drug works to decrease the amount of glutamate (an excitatory neurotransmitter) in the brain. In clinical trials, riluzole has been shown to delay the need for tracheostomy and death by a few months.39
The illness trajectory for ALS is devastating because
the patient remains cognitively intact while wasting away. The challenge of nursing care is to guide the patient in use of moderate intensity, endurance-type exercises for the trunk and limbs, as this may help to reduce ALS spasticity.40 Additionally, the nurse needs to support the patient's cognitive and emotional functions. Nursing interventions may include (1) facilitating communication, (2) reducing risk of aspiration, (3) decreasing pain secondary to muscle weakness, (4) decreasing risk of injury related to falls, (5) providing diversional activities such as reading and human companionship, and (6) helping the patient and family manage the disease process, to include grieving related to loss of motor function and ultimately death.
risks that increase surgical risk
Diabetes
Age
Obesity
Electrolyte imbalance
Cardiovascular and respiratory problems
-Renal and liver problems
What electrolyte imbalance do we need to worry about in surgery,,,,
Potassium
where is all the K
in the cells and released due to cell damage from surgery
problem livers
problem with platlet production, big problems with surgery.. no clotting factors.
portal hypertension in the liver will cause
varicies
Respiratory problems of surgery
atelectasis
Pneumonia
Renal and liver
poorl tolerate of general anesthesi
Anticoagulants
-Heparin
-Coumadin
-ASA
-Others
who gets consent and what is the PARQ
person doing the procedure
P plan
A alternitives to surgery
R risks
Q do you have any questions
Girdle stone procedure
cut femer head off ,, stiff leg
what is informed consent
when they know in there terms what is going to be done.
when do you start discharge planning
the day they find out they are having surgery,, after care needs to be looked at
Discharge planning
baseline, what could they do before surgery
Learning needs,
Medications, what were they on prior to surgery
Who do you teach about the surgery
Patinet
Family
Care takers,,
NIS
nurse information systems
curculator
non sterile patient advocate
scrub
sterile in or
RNFA
RN fist assistant
NIS
Nurse information systems person
CRNA
certified nurse anest
NP
nurse practioner
CNS
clinicle nurse specialist
Sterile
1/million chance of finding a micro organism
-Gas plasma/ hydrogen peroxide
-Ethylene oxide,poison
-Steam
-Dry heat
Aseptic technique
only sterile items are used within the sterile field
types of anesthesia
-General
-Regional
-Monitored anesthesia care
-conscious sedation
-local anesthesia
epineph
longer local anesthesia
palliative surger
relieve sysmptoms
Ablative suregery
cutting somthing out
Risk Minor surgery
-dont invade body cavity no general anesthetic
urgent surgery
the next day or so
Emergency surgery
next available room
Time Out
correct
patinet
site
surgery
imaging
does everyone concur
mortality for malignant hyper
in the past 80%
Mortality with proper treatment 7%
triggers for malig hyper
stop triggering events
hyperventilate
dantrolene, 2 to 3 mg/kg iv continue up to 10 mg/kg
Sodium bicarb
cool patient
malig hyper
autosomal dominant if your mother had it you dont get inhalation or SUX
Apiration
regurgitaion
with decreased laryngeal-pharyngeal function......
thyroid hormones regulate
energy and metabolism and what
Hyperthyroidism
Hyperactivity, increase and synthesis of thyroid hormones
-cause nausea, diarhea
-agitation
-exopthalmos
-Diaphoretic, edema,tachypnea
-tachycardia
What is a goiter
this is a result of hyperthyroidism, big neck
management of hyperthyroidism
there are drugs to use
-iodine
-beta blockers for heart rate
-iodine
-surgery
Complications in taking out thyroid glands
- you can release thyroid into the body
- major bleeding
Thyroid storm
-Very high fever and tachycardia
-it rare
-different things can bring it on and they can go into heart failure and shock
-temp up to 105.3
Treatment for thyroid storm
replace fluids
manage fever
Hypothyroidism
-Frim hypothalmic, pituitary or thyroid insufficiency
-can progress to life threatening to myxidema
Hypothyroidism clinicle signs
they are very tired.
heavy period
low blood pressure
myxedema
management of hypothyroid problems
thyroid hormone replacement
high bulk low calorie diet
Common cause of cushing syndroem ,, exogenous cause
steroids
what are endogenous cause of cushings syndrome
pituitarey tumor
management of cushing syndroem
normalize hormone secretions
pituitary tumor
drug therapy
Discontinue exogenous steroids
What is it
what causes it
manifestation of it
management of it
study concept
Addisons disease causes
weight loss
hyperpigmentation
anorexia
anemia
hyponatremia
hyperkalemi
HYPOTENSION
Management of Addisons disease
daily weights
monitor vitals
coricosteroids, extra during stress
-patient teaching about signs and symptoms
SIADH
oat cel carcinoma of lung
neoplastic diseases
CNS disorders
Big concern with SIADH
Hyponatremia and electrolyte imbalance
managment of SIADH
manage sodium and make sure to go slow on the fluids
during times of stress
blood suger can go up
need to know lab values for
DKA
and
Non DKAHO
Diabetes insipidus
massive urine output
Exocrine glands
Secrete their substances into ducts that then empty into the body cavity or onto a surface
Example: salivary glands
Endocrine glands
Do not have ducts, secrete their substances directly into the blood
Hypothalamus
Located at the base of the brain
Actually is the “master gland”
Secretes hormones that regulate the pituitary
Contains neurons that receive input from
Brainstem
Limbic system
Thyroid
Located in the anterior portion of the neck in front of the trachea.
Two encapsulated lateral lobes connected by a narrow isthmus
Highly vascular
Regulated by tropic hormones from the anterior pituitary
Regulates the metabolism
Parathyroid
Regulates the blood calcium level
Adrenal Glands
Located on the upper portion of each kidney
Divided into two parts
Medulla – 10 to 20 % of the gland
Cortex – 80 to 90% of the gland
Each has distinct functions and acts independently
Adrenal Medulla
Sympathetic postganglionic neurons
Secretes catecholamines
epinephrine and
norepinephrine
Adrenal Cortex
Secretes more than 50 steroid hormones Cholesterol is the precursor for steroid hormone synthesis.
Pancreas
Located behind the stomach
Anterior to the second lumbar vertebrae
Long, tapered, lobular, soft
Exocrine and endocrine functions
Hormone secreting portion
Islets of Langerhans
4 types of hormone secreting cells
Alpha, beta, delta and F cells
Regulation of blood sugar
Hormones
Molecules that are synthesized and secreted by specialized cells released into the blood and exert biochemical effects on target cells at a distance from their site of origin.
-Common characteristics
Secretion in small amounts at variable but predictable rates
Circulation through the blood
Binding to specific cellular receptors either in the cell membrane or within the cell
Classified by their chemical structures
Lipid soluble – steroids
Peptides and proteins, amino acids and amines
What about calcium
Calcium is a well established intracellular messenger for a number of hormones
Thyroid hormones regulate
Energy metabolism
Growth and Development
Disorders of the thyroid gland include:
Enlargement
Benign and Malignant nodules
Inflammation
Hyperfunctioning
Hypofunctioning
Hyperthyroidism
Hyperactivity, increase and synthesis of thyroid hormones.
Thyrotoxicosis, clinical syndrome hypermetabolism from excess T4, T3.
Graves disease ( most common form, 75 % cases) increase thyroxine (T4). Enlarges thyroid gland (goiter).
Autoimmune (Graves).
Enlarged thyroid and excess hormone
Exacerbations and remissions
May destroy thyroid and cause hypothyroidism
Graves disease,
exopthalmos, protrusion of eyeballs from orbits. (impaired venous drainage to fat deposits and edema). Corneal ulcers and vision loss if lids don’t close.
Nursing Assessment: Subjective
Hpermetabolic state
Weight loss, nervousness,
diarrhea, palpitations,
Management
hypermetabolic state
Antithyroid drugs
Thyroid hormone antagonists propylthiouricil (PTU), methimazole, (Tapazole) to block thyroid hormone synthesis
Beta-adrenergic blocker (propanolol (inderal)) until antithyroid drugs work and manage tachycardia.
Iodine (Potassium 131 I to decrease thyroid gland’s capacity for hormone production.
Thyroidectomy
Lifelong medical supervision
Thyrotoxic crisis
Severe tachycardia, heart failure, shock, hyperthermia (up to105.3 F),
Treatment for Thyroid Storm
Drug therapy to reduce circulating thyroid.
Supportive therapy:
Managing respiratory distress, fever, fluid replacement, elimination or management of initiating stressors.
Hypothyroidism
From hypothalmic, pituitary, or thyroid insufficiency, or resistance to thyroid hormone.
Can progress to life-threatening myxedema.
Causes: autoimmune disease (Hashimoto’s thyroiditis), overuse of anti-thyroid drugs, thyroidectomy,malfunction of pituitary, Radiation
Hypometabolic State
Fatigue, muscle weakness, depression, lethargy, forgetfulness, sensitivity to cold, weight gain, constipation, menorrhagia
-puffy face, hands, feet (edema): hoarseness; periorbital edema; upper eyelid droop; dry, sparse hair; rough dry skin
-Cardiovascular:
Decreased Cardiac Output; slow pulse, signs of poor peripheral circulation
Myxedema
Progressive stupor
Hypoventilation
Hypoglycemia
Hyponatremia
Hypotension
Hypothermia
Management of hypothyroidism
Gradual thyroid hormone replacement (Synthetic T4 and occasionally T3).
High-bulk low calorie diet
Cathartic and stool softeners
Surgical excision, chemotherapy, or radiation for tumors.
Cushing Syndrome
Spectrum of clinical abnormalities caused by excess of corticosteroids
Manifestations of cushing syndrome
Obesity, Buffalo Hump (fat on back of neck)
Thin fragile skin, petechial hemorrhages, striae, bruises, red cheeks, poor wound healing. Moon face.
Hypervolemia, Hypertension, peripheral edema
Anorexia.
Muscle wasting and fatigue, osteoporosis.
Immune suppression.
Psychosis, depression, euphoria.
Management of cushing syndrome
Normalize hormone secretion.
Pituitary tumor: surgery
Drug therapy (ex: Mitotane)
Discontinue exogenous steroids.
Addison’s Disease
Weight loss
Hyperpigmentation
Hyponatremia, hypovolemia, hypotension
Management
Addison’s
Assessment and monitoring of VS, fluid volume deficit and hypotension, and electrolyte imbalance.
Daily weights.
Corticosteroids. Extra during stress.
Education on management.
Teach patient to recognize signs and symptoms of steroid deficiency or excess steroids and report these to the doctor right away.
Syndrome of Inappropriate Antidiuretic Hormone SIADH
Potentially life threatening condition that disturbs fluid and electrolyte imbalance.
Results when excessive ADH secretion is triggered by stimuli other than increased extracellular fluid volume, reflected by hypotension.
Causes of
SIADH
or
Inappropriate Antidiuretic Hormone
Oat cell carcinoma of lung (Most common cause: secretes excessive levels of ADH).
Neoplastic diseases (pabcreatic, prostate, Hodgkin’s, Renal carcinoma).
Other causes: CNS disorders, pulmonary disorders, drugs, etc.
Signs and symptoms
Syndrome of Inappropriate Antidiuretic Hormone SIADH
Hyponatremia and electrolyte imbalances
First: Thirst, anorexia, fatigue, lethargy
Then: vomiting, weight gain, edema, decreased urine output, neurologic changes, decreased reflexes, coma.
Management
of
Syndrome of Inappropriate Antidiuretic Hormone SIADH
Monitor Sodium closely.
Restricted water intake (500 to1000 ml/day.
Administration of 200 to 300 ml of 3% saline solution to slowly increase serum sodium level
Correction of underlying cause.
Surgical resection, irradiation, or chemotherapy.
Demeclocycline (Declomycin) to block renal response to ADH if fluid restriction is ineffective.
Lasix with normal or hypertonic saline to maintain urine output and block ADH secretion.
DKA
Causes
Infection is the most common precipitating cause of DKA.



Other causes include undiagnosed diabetes; uncontrolled diabetes; severe illness; stress; & poor access to diabetic supplies.
Pathophysiology of DKA
In persons with type 1 diabetes, there is an inability of muscle and adipose tissue to use insulin. Glucagon triggers an accelerated rate of hepatic glucose through glycogenolysis, and glyconeogenesis.



To compensate for starvation of peripheral muscles, lipolysis is stimulated and ketones are produced as a by-product of free fatty acid metabolism in the liver.



Since glucose and ketones are osmotically active, their excretion in urine leads to osmotic diuresis and dehydration. Rehydration alone may decrease plasma glucose levels; however, one needs insulin to prevent severe dehydration, electrolyte imbalance, metabolic acidosis, coma, and death.



Signs & symptoms of DKA can be confused with other conditions. The abdominal tenderness, nausea, vomiting may seem like the flu.
HHNS

Causes
Commonly found in the elderly patient with mild or undiagnosed type _ 2___ diabetes who is on oral agents and is not monitored well. Also, persons who are unable to communicate their needs may potentially become dehydrated from lack of fluids. Any elderly person with or without diabetes who has deteriorated CNS function and is severely dehydrated should be evaluated for HHNS.
Pathophysiology
of HHNS
The patient with HHNS is still producing endogenous insulin and there is absence of significant ketosis. THIS IS THE PRIMARY DIFFERENCE BETWEEN DKA and HHNS. Both disorders have hyperglycemia in common.



Extreme hyperglycemia, the hallmark of HHNS, occurs. This results from the decrease in urine output (due to severe osmostic diuresis resulting in decrease in blood volume and decreased glomerular filtration rate). The route of elimination for glucose is reduced or absent. Hepatic glucose production continues to occur. The glucose is released into a shrinking extracellular space which leads to a high concentration of glucose
Lab Results
DKA, HHNS, or BOTH
__DKA___ blood glucose range > 250 - 600 mg/dL (may be as high as 1500 mg/dl*)

__BOTH__ serum potassium low, normal, or high

__HHNS__ blood glucose range > 600 mg/dL (usually 600 – 2000*)

__DKA ___ serum pH range < 7.2**

__DKA ___ serum osmolality < 350 mOsm/kg (usually 300 – 350**)

__HHNS__ serum pH 7.35 - 7.45 or slightly acidotic (pH < 7.4**)

__HHNS__ serum osmolality > 350 mOsm/kg
fruity breath odor
conversion of acetoacetate to acetone
dehydration
severe dehydration of HHNS
hypotension, tachycardia, dry mucous membranes
inverted T waves
low potassium
vascular occlusion
severe dehydration of HHNS
hyporeflexia
low potassium
decreased sodium & chloride
metabolic acidosis
increased sodium
treatment related fluid overload
and \dehydration
lactic acidosis
tissue anoxia 2° hemoconcentration
decreased bicarbonate
metabolic acidosis
decreased phosphorus & magnesium
administration of glucose & insulin
Collaborative Management

Diabetic Ketoacidosis (DKA) /Hyperosmolar Hyperglycemic NonKetotic Syndrome (HHNS):
Get an IV going

- rehydration, reversing shock, restoring potassium balance, correcting pH, administering insulin, and restoring electrolyte balance.



The nurse ensures the patient has urine output before administration of potassium and monitors the calcium level when administering phosphate.



The nurse understands that low-dose insulin administered intravenously is the most widely used method of insulin administration. There is a reduced risk of hypoglycemia and the potassium decreases are more predictable.