Respiratory Med Surge

Front 1

ACID
A substance that is capable of losing hydrogen ions

ACIDOSIS
Condition of increased hydrogen ion concentration in the blood

ALKALOSIS
Condition of decreased hydrogen ion concentration in the blood

ALVEOLAR VENTILATION
Volume of air that undergoes gas exchange

ANATOMIC DEAD SPACE
Portion of respiratory system from nose to respiratory bronchioles that functions only as an air passageway; about 25% of air inhaled with each breath remains here and is therefore unavailable for gas exchange

BASE
A substance that is capable of accepting hydrogen ions

BUFFER
A weak acid or a weak base that transfers hydrogen ions between solutions to maintain acid-base balance

COMPLIANCE
Elastic property of lungs and thorax; also referred to as distensibility

DIFFUSION
Movement of gas from an area of higher pressure to an area of lower pressure

EXPIRATION
Movement of gas from respiratory system into atmospheric air; process is generally passive, but may become more conscious and forced with obstructive lung disease.

INSPIRATION
Movement of air from atmosphere into respiratory system process is generally passive but may be voluntary

OXYGEN SATURATION
Percentage of oxygen bound to hemoglobin compared to the volume that the hemoglobin is capable of binding

PERFUSION
Circulation of blood into tissues and cells

pH
Refers to hydrogen ion concentration of a solution; indicator of the ratio of acid and base in the blood; a lower pH indicates greater hydrogen ion concentration and greater acidity; a higher pH value indicates lower hydrogen ion concentration and high alkalinity

PULMONARY VENTILATION
Total volume of gas exchange between atmosphere and lungs

RESPIRATION
Mechanical and metabolic processes involved with oxygen transport from atmospheric air into blood and carbon dioxide transport from blood back into atmospheric air

VENTILATION-PERFUSION MISMATCH
Clinically significant imbalance between volume of air and volume of blood circulating to the gas exchange area of the lungs; average ratio is 4 L of air passing into alveoli for every 5 L of blood that flows into alveoli (ratio of 0.8); also commonly known as VQ (ventilation quotient) mismatch

OVERVIEW OF ANATOMY & PHYSIOLOGY
RESPIRATORY SYSTEM STRUCTURES
UPPER RESPIRATORY TRACT (CONDUCTING AIRWAYS)
NOSE
Paranasal sinuses
Pharynx
Larynx
trachea
LOWER RESPIRATORY TRACT (CONDUCTING AIRWAYS & GAS EXCHANGE AIRWAYS
Bronchi-Alveoli-Lungs-Pleura
Accessory structures-Rib cage-Intercostal muscles-Diaphragm
Respiratory system functions
Pulmonary ventilation-Alveolar ventilation-Ventilation phases
Respiratory system pressures
Intrapulmonary pressure-Intrapleural pressure-Intrathoracic pressure
Respiratory tissue properties
Compliance-Elastic recoil-Distensibility-Stiffness
Airway resistance
Lung volumes and capacities-Body position-Perfusion
Pulmonary circulation
Bronchial circulation-Characteristics of respiratory system circulation
Diffusion
Fick's Law-Variables that influence gas exchange-Ventilation-perfusion relationship
Nervous system control of breathing:
initiates with the medulla oblongata and pons of the brainstem

DIAGNOSTIC TESTS & ASSESSMENTS
RADIOLOGICAL STUDIES
PULSE OXIMETRY
PULMONARY FUNCTION TEST
BRONCHOSCOPY
THORACENTESIS
LAB

COMMON NURSING TECHNIQUES & PROCEDURES
AIRWAY MANAGEMENT
ARTIFICIAL AIRWAYS
TECHNIQUES FOR AIRWAY CLEARANCE
BODY POSTIONING
PHYSIOLOGY-FLUID SHIFT THEORY
SPECIFIC CONDITIONS
UNILATERAL LUNG DISEASE
ACITE RESPIRATORY DISTRESS SYNDROME
OXYGEN ADMINISTRATION
PULMONARY HYGIENE
TRACHEOSTOMY CARE
LARYNGECTOMY CARE
RESPIRATORY ISIOLATION
OSHA-STANDARDS

NURSING MANAGEMENT OF CLIENT THORACIC SURGERY
PREOP
POST OP
CARE OF CLIENT WITH CHEST TUBE
POSITIONING CLIENT AFTER LUNG SURGERY

DISORDERS OF RESPIRATORY SYSTEM
OBSTRUCTIVE PULMONARY DISEASES
Emphysema
-r/t ciragette smoking
Dx in younger adults hereditary deficiency
Air trapping respiratory…
Work of breathing requires more energy
-Assessment-Pink puffer barrel chest, pursed lip breathing, obvious use of accessory muscles when breathing
-Therapeutic management
Administer & teach clients about bronchodilator therapy & use of measured dose (metered dose) inhalants
Position clients to optimize & maintain airway & effective breathing patterns-head elevated
-Client Ed-Energy conservation techniques

CHRONIC BRONCHITIS
Description-a form of COPD (cough lasting at least 3 months during 2 yers
R/T cigarette smoking
-Chronic respiratory inflammation from air pollution or occupational substances such as coal, glass & asbestos
-Chronic inflammation of airways produces hyperplasia of mucous glands, resulting in excessive sputum production
Assessment
Clinical manifestation
-Frequent cough, occurring winter with foul smelling sputum
Dx & lab test findings
-Pulmonary function indicates increased residual volume, decreased vital capacity, FEV1 & FEV1/FVC ratio
Medication therapy
-Immunization pneumococcal (single dose or q 6 years), influenza (yearly)
-Antibiotics
-Bronchodilators (controversial with COPD, but maintenance therapy may be used to reduce dyspnea & attempt to increase FEV1
Client education-Smoking cessation

ASTHMA
-Intrinsic etiologies-uncertain causes; physical or psychologica stress, exercise-induced
-Extrinsic etiology-antigen-antibody (allergic) reaction to specific irritants; common triggers include air pollutants, sinusitis, cold and dry air, medications, food additives, hormonal influences, and gastroesophageal reflux
Assessment-Clinical manifestations
-Severe dyspnea
-Wheezing
-Cough
-Feelings of chest tightness
-Prolonged expiration
Therapeutic management
-Acute episodes are managed with inhaled beta agonists, bronchodilators, anti-inflammatory agents, corticosteroids, and oxygen therapy; in severe cases, mechanical ventilation may be instituted
Planning & Implementation-ID/avoid/remove precipitating factors
Medication therapy
-Short acting beta-agonist inhaler: used for mild symptoms occurring twice weekly or less; also used for intermittent symptomatic relief and may be combined with long-acting medications
Client Ed-Use peak flow meter for daily self-assessment of asthma status

RESTRICTIVE PULMONARY DISEASE
Pleural effusion, empyema, chylothorax
PLEURAL EFFUSION-Accumulation of fluid in pleural spaces
-Assessment-clinical manifestations
Worsening dyspnea
Diminished or absent breath sounds
Dullness to percussion on affected side
Chest wall pain
Fever, persistent cough, night sweats, weight loss with empyema
-Planning and Implementation
Monitor respiratory & oxygenation status
Healthcare provider performs thoracentesis; thoracostomy if indicated
Treatment of underlying cause
Provide supplemental oxygen if indicated
Adequate nutrition & adequate protein intake

PNEUMOTHORAX/HEMOTHORAX
Description
-Spontaneous rupture of air-filled bleb allows pathway for air movement between respiratory system and pleural space; collapse of involved tissue may seal leak with minimal client symptoms (primary & secondary)
-Tension-disruption of chest wall or lungs causes air accumulation in the pleural space; pressure on the mediastinum causes pressure on the other lung and interrupts venous return to the heart
Assessment-clinical
-Dyspnea
Tracheal deviation toward unaffected side
Diminished breath sounds
-Therapeutic management
In mild cases-no chest tube is required;
Placement of chest tube with water seal drainage
-Client Ed
Purpose of chest tube
Activity limitations
Pain management

ATELECTASIS
-Description
Collapsed alveoli
Common complication in post op or immobilized clients
-Assessment
Low grade fever
Breath sounds diminished or absent in affected area
Diminished rate and depth of respiration
-Therapeutic management
Primary goal is prevention of atelectasis
Chest physical therapy & general pulmonary hygiene measures
Intermittent positive pressure breathing treatments
Supplemental oxygen as indicated
-Planning & Intervention
Monitor resp & oxygenation status
Deep breathing & coughing exercises

PNEUMONIA
Description
-Acute inflammation of lung parenchyma (alveoli & respiratory bronchioles)
-Classified as viral versus bacterial, community acquired versus hospital acquired, atypical, or pneumocystis
Assessment
-Viral
Fever-low grade
Cough-nonproductive
White blood cell count-normal to low elevation
Chest x-ray-minimal changes evident
Clinical course-less severe than pneumonia of bacterial origin
-Bacterial
Fever-high
Cough-productive
White blood cell count-high elevation
Chest x-ray-obvious infiltrates
Clinical course-less severe than pneumonia of bacterial origin
-Therapeutic management
Antibiotic therapy, analgesics, antipyretics
Oxygen therapy to treat hypoxemia
-Planning & implementation
Maintain patent airway
Monitor respiratory and oxygenation status
Provide supplemental oxygen as indicated
Be prepared to initiate mechanical ventilatory support
Provide nutritional support & increased fluids via approx
Provide adequate opportunities for physical rest
-Client Ed
Immunization against influenza and pneumococcal pneumonia
Activity limitations and importance of rest

PUMONARY TUBERCULOSIS
Description-
-Lung infection caused by Mycobacterium tuberculosis
-Any tissue can be infected, but tuberculosis os often found in the lung
Assessment
-Frequent cough with copious frothy pink sputum-nonproductive cough early in the morning develops first as an early symptom
Lab & dx
-Positive tuberculin skin test (indicated exposure)
-Appearance of characteristic Ghon tubercle on chest x-ray
-Positive acid-fast bacillus sputum cultures
Planning & Implementation
-Monitory respiratory & oxygenation status
-Provide adequate nutrition & hydration
-Standard precautions
Medication therapy
-Antibiotic prophylaxis
-Isoniazid (INH) drug of choice for 5 months
-INH drug of choice for 12 months if abnormal chest x-ray or high-risk population such as with HIV or drug-induced immunosuppression

Active disease treatment options prescribed by Centers for Disease Control (CDC)
-Option 1: INH, rifampin (Rifadin), pyrazinamide (Tebrazid) & ethambutol (Myambutol) or streptomycin given daily or 2 to 3 times weekly (if therapy verified); if cultures report sensitivity to rifampin or isoniazid, ethambutol or streptomycin can be stopped: minimal 6 months drug therpy; drug therapy continues for at least 3 months after first negative sputum culture obtained
Client Education
-Infection control measures,
-No special precautions
-Teach client about adverse effects of medications, including but not limited to the following-INH-Rifampin-Pyrazinamide

PULMONARY EMBOLISM
Description-Emboli lodge in pulmonary vasculature and obstruct adequate blood flow through pulmonary capillaries
Ventilation-perfusion mismatch-a clinically significant imbalance between volume of air and volume of blood circulating to the gas exchange area of the lungs; causes impaired gas exchange
Assessment
Restlessness
Vital signs-tachycardia, tachypnea, hypotension, fever
Chest pain
Hemoptysis
Therapeutic management
-Oxygen therapy
-Anticoagulant therapy
-Embolectomy
-Thrombolytic therapy
-To prevent future pulmonary emboli, an intracaval filter may be inserted into the inferior vena cava to trap emboli from a known source
Client education
-Prevention of thromboembolism
-Avoid immobility as much as feasible
-Signs/symptoms of venous occlusion


BRONCHOGENIC CARCINOMA
Description
-Lung cancer is the leading cause of death resulting from malignancy
-Five-year survival rate is less than 15%
-Greater than 90% of lung cancers originate in the bronchus epithelium
Assessment
-Symptom onset is often late in the course of the disease
-Persistent cough (progressively increases) with or without hemoptysis
-Localized chest pain
-Dyspnea
Therapeutic Management
Surgical resection
-Pneumoectomy-removal of an entire lung
-Lobectomy-removal of a lobe of the lung
-Segmentectomy (segmental resection)-removal of a segment or segements of a lung
-Wedge resection-dissection and removal of a defined area in the lung

CANCER OF LARYNX
Description-
-Most laryngeal tumors are benign
-Most common form of malignant laryngeal cancer is squamous cell carcinoma
Etiology
-Primary etiologies for laryngeal cancer include long-term cigarette smoking and alcohol ingestion
-Contributing factors include chronic laryngeal irritation caused by singing, air pollution, and environmental hazards
Assessment
-Hoarseness
-Palpable jugular nodes
-Change in voice characteristics
-Pain when swallowing
Therapeutic management
-Choice of treatment depends on the stage of the disease and the general condition of the client
-Radiation therapy or brachytherapy; brachy therapy is the placement of a radioactive source next to the tumor site
-Chemotherapy
-Laryngectomy
-Radical neck dissection
Planning & Implementation
-Biopsy of laryngeal lesions and other dx tests, such as CT scan, MRI of head and neck, chest x-ray
-Maintain patent airway (tracheostomy of performed with laryngectomy)
-Pain management
-Provide alternate means for communication as previously discussed and plan for permanent means of communication (artifical larynx or esophageal speech)

THORACIC TRAUMA
Description-Alteration of breathing mechanics and/or gas exchange caused by respiratory system trauma
R/T -blunt trauma
Assessment-Chest pain, may be severe such as with flail chest
Planning & Implementation
-Ventilation support
-Be prepared to initiate mechanical ventilation
-Maintain IV access
-Placement o chest tube with water seal drainage may be indicated
-Pain management
Medication Therapy
Opioid analgesics, epidural analgesia may be appropriate
Client Ed
-Techniques for pulmonary hygiene
-Pain management -pt controlled analgesia may be appropriate

Back 1

Afterload
Resistance that ventricles must overcome to eject blood into systemic circulation; directly related to arterial blood pressure

Angina pectoris
Chest pain resulting from restricted blood flow to myocardum

Cardiac cycle
One complete heartbeat; includes two phases; systole (ventricular contraction) and diastole (ventricular relaxation and refilling)

Cardiac output (CO)
Volume of blood in liters ejected by the heart each minute; indicator of pump function of the heart; normal adult CO is 4 to 8 L/min; CO=HR x SV

Contractility
Strength of contraction regardless of preload; decreased by hypoxia and some drugs (beta blockers and calcium channel blockers); increased by drugs (digoxin and dopamine)

Coronary artery disease (CAD)
Refers to buildup of atherosclerotic plaque in coronary arteries that restricts blood flow to heart muscle

Cor pulmonale
Right-sided failure and enlarged right atrium caused by chronic pulmonary hypertension

Ejection fraction (EF)
Portion of blood ejected during systole, compared with total ventricular filling volume, normal EF is 55-65%

Ischemia
Decreased supply of oxygenated blood to heart muscle

Infarction
Myocardial tissue injury from lack of oxygenation

Jugular venous distention (JVD)
Increased pressure in jugular veins, visible more than a few millimeters above clavicle with client supine with head of bed raised to 45-degree angle

Preload
Degree of myocardial fiber stretch at end of ventricular diastole; influenced by ventricular diastole volume and myocardial compliance

Pulmonary edema
Significant fluid overload in lungs with acute exacerbation of left heart failure

Regurgitation
Improper or incomplete closure of heart valves, resulting in back flow of blood

Stenosis
Condition in which heart valve leaflets are fused together, have a narrow opening, or are stiff, unable to open or close properly

Stroke volume (SV)
Volume of blood ejected from left ventricle each cardiac cycle

Tamponade
Life-threatening medical emergency resulting from excess fluid collection in pericardial sac; interferes with heart filling and severely decreases cardiac output; if left untreated will lead to cardiac arrest and possible death.

OVERVIEW OF ANATOMY AND PHYSIOLOGY OF THE HEART

• STRUCTURES OF THE HEART
○ VALVES OF THE HEART
• FUNCTION OF THE HEART
• CARDIAC CONDUCTION SYSTEM
○ COMPONENTS OF THE CARDIAC CONDUCTION SYSTEM ARE AS FOLLOWS
§ SINOATRIAL (SA) NODE
§ INTERNODAL PATHWAYS
§ ATRIOVENTRICULAR (AV)
§ BUNDLE OF HIS
§ BUNDLE BRACHES
§ PUKINJE FIBERS
• CARDIAC CYCLE
• CARDIAC OUTPUT
HEART RATE
STROKE VOLUME
PRELOAD
AFTERLOAD
CONTRACTILITY
• AUTONOMIC NERVOUS SYSTEM

DX TESTS AND ASSESSMENT
• LAB TESTS
• ELECTROCARDIOGRAPHY
• ECHOCARDIOGRAPHY
• PHONOCARDIOGRAPHY
• CORONARY ANGIOGRAPHY/ARTERIOGRAPHY
• CARDIAC CATHETERIZATION
• RADIONUCLIDE TESTS
• HEMODYNAMIC MONITORING

COMMON NURSING TECHNIQUES AND PROCEDURES
• DYSRHYTHMIA MONITORING
• CARDIAC SURGERY OR ENDOVASCULAR INTERVENTIONS
• VALVULAR SURGERY REPAIR OR REPLACMENT OF DYSFUNCTIONAL VALVE
• PACEMAKERS-PERMANENT PACEMAKERS

MYOCARDIAL INFARCTION (MI)
DESCRIPTION-
myocardial injury from sudden restriction of blood supply to a portion of the heart

R/T
○ Main cause is coronary artery disease (CAD), the buildup of atherosclerotic plaque in coronary arteries that restricts blood flow to the heart
○ Coronary artery blood flow is blocked by atherosclerotic narrowing, thrombus formation or (less frequently) persistent vasospasm; my myocardium supplied by the arteries is deprived of oxygen
○ Angina pectoris
• Assessment of MI
○ Chest pain unrelieved by nitroglycerine or rest; may be crushing substernal pain; may radiate to jaw, neck, back or left arm
○ ECG (12-lead): ST elevation, accompanied by T-wave inversion; and later new pathologic Q wave in leads that reflect the area of damage
• Planning & Implementation
○ Assess pain status freq with pain scale or appr tool; pain is usually first presenting sign of new or extended MI
○ Assess hemodynamic status incl BP, HR, LOC, skin color and temp freq (every 5 min during episodes of pain; every 15 min post-pain during the acute phase to eval CO; cont to monitor freq (every 1-2 hrs) for the first 24 hr post -MI
○ Perform 12-lead ECG immediately with new pain or changes in level or character of pain to ID ischemia and injury
• Medication Therapy
○ Administer nitroglycerine as prescribed to dilate coronary vessels and increase blood flow; sublingual nitroglycerine may be given 1 tab every 5 min up to 3 times to relieve chest pain; IV nitroglycerine is administered to dilate coronary arteries and increase blood flow to the heart
○ Administer anticoagulants (IV heparin) and aspirin (antiplatelet) as ordered to prevent additional clot formation, monitor PTT to maintain heparin at therapeutic level
○ Monitor neurological status freq for changes; alteplase recombinant and streptokinase are not clot-specific and will dissolve other clots-can cause thrombolytic (hemorrhagic) CVA, a life-threatening complication
• CLIENT ED
○ Stress importance of immediately reporting chest pain or signs of decreased CO
○ Instruct about bleeding precautions if client is on anticoagulant therapy; use soft toothbrush, electric razor, avoid trauma or injury, wear or carry medical alert ID

HEART FAILURE
○ DESCRIPTION-
§ Inability of heart to pump adequate blood to meet metabolic needs of the body
§ Formerly called congestive heart failure
○ R/T
§ Multiple causes include myocardial damage from MI, incompetent valves, inflammatory conditions of heart, cardiomyopathy, pulmonary hypertension (causes right-sided failure, called cor pulmonale)
§ Depending up cause-heart failure presents initially as right-sided failure or left-sided failure; as it progresses the other side becomes affected
□ Left sided-left ventricle has reduced capacity to pump blood into systemic circulation causing decreased CO and stasis or backup of blood into pulmonary circulation
□ Right sided-right ventricle has reduced capacity to pump blood into pulmonary circulation causing stasis or backup of blood into the venous circulation
○ Assessment
§ Left failure-dyspnea on exertion (often first clinical sign), orthopnea, paroxysmal nocturnal dyspnea, new S3 (ventricular gallop), crackles, pulmonary edema is acute life-threatening left heart failure,
§ Right failure-edema of lower extremities; jugular venous distention (JVD) is visible more than a few centimeters above clavicle with the client lying at a 45-degree angle, abdominal discomfort and nausea occur from fluid congestion in the abdominal organs
○ DX
§ CVP is elevated in right-sided failure
○ Priority NX
§ Decreased cardiac output, excess fluid volume
○ Planning and Implementation
§ Acute phase
□ Maintain client in sitting ps to decrease pulmonary congestion and facilitate improved gas exchange
□ Auscultate heart and lung sounds freq; increasing crackles, increasing dyspnea, decreasing lung sounds or new S3 heart sound indicate worsening failure
□ Monitor serum electrolytes to detect hypokalemia secondary to diuretic therapy
□ Monitor accurate intake and output (may require urinary drainage catheter to allow for accurate measurement of urine output) to evaluate fluid status
§ Chronic heart failure
□ Monitor daily weights to evaluate changes in fluid status
○ Medication therapy
§ Angiotensin II receptor blockers (ARBs) interrupt vasoconstrictor and aldosterone-secreting effects of antiotensin II; prescribed for similar reasons as ACE inhibitors
§ Digoxin (Lanoxin) to improve contractility and correspondingly increase stroke volume and cardiac output; take apical pulse for 1 full minute and withhold if heart rate is less than 60 or greater than 120
○ Client Ed
§ Include family emembers
§ Weight monitoring-teach importance of measuring and recording daily weights; report unexplained increase of 3-5 pounds-most sensitive indicator of incr fluid overload
§ Diet-sodium restriction to decr fluid overload and potassium-rich foods to replenish loss from medications; do not restrict water intake unless directed (this will not decr fluid retention)
§ Medication regime-explain the importance of following all med instructions; remind cl that although freq urination is bothersome, regular diuretic therapy prevents fluid overload and acute exacerbation; instruct client how to take radial pulse for one full minute before taking digoxin and to withhold dose and call prescriber if <60 or > 120.

ENDOCARDITIS (INFECTIVE, SUBACUTE BACTERIAL)
• Description-
○ Inflammation of inner layer of heart
○ Usually involves cardiac valves
• R/T
○ Microorganism in blood
• Assessment
○ Acute; spiking fever & chills; signs of heart failure; WBC elevation
• Planning & Implementation
○ Use anti-embolism stockings to prevent thrombus formation
• Medication
○ Consists of antibiotics given by IV route
○ Given for 6 weeks
• Client Ed
○ After one episode of endocarditis client is susceptible to repeated infections because of lesions on endocardium
○ Symptoms to report to physician such as fever, anorexia, malaise
○ Importance of prophylactic antibiotics prior to invasive procedures and routine dental care

VALVULAR DISORDERS
• Description
○ Defects in structure or function of valves that interfere with proper cardiac circulation
○ Two major categories
§ Stenosis-heart valve leaflets are fused together, opening is narrow, stiff, and unable to open or close properly
§ Regurgitation-there is improper or incomplete closure of heart valves, resulting in backflow of blood
○ R/T
§ Multiple causes including rheumatic heart disease (most common), congenital, MI, endocarditis
○ Client Ed
§ Monitor PT/INR values regularly because the effects of warfarin are influenced by physiological changes in the body, diet changes, or changes in medication
§ Maintain consistent amount of food containing vitamin K in the diet including green leafy vegies; variations may alter the effects of warfarin (Coumadin)
§ Methods to prevent endocarditis

CARDIOMYOPATHY
• Description
○ Is an abnormality of the heart muscle
○ Leads to functional changes in the heart
• Assessment
○ Fatigue with all types
• Planning & implementation
○ Monitor indicators of level of heart failure (vital signs, lung sounds, edema, dyspnea, activity tolerance)
○ Encourage rest and minimize stressful situations to reduce the workload on the heart

PERICARDITIS
• Description
○ Inflammation of the pericardium
• R/T
○ Acute pericarditis; may have multiple causes including infectious processes (viral the most common organism), post-MI (Dressler's syndrome), status, neoplasms, trauma, uremia, connective movement of the myocardium and restricting diastolic filling
• Planning & Implementation
○ Monitor for complications, especially cardiac tamponade (Medical emergency) resulting from excess fluid collection in the pericardial sac that interferes with heart filling and function); signs include
§ Jugular venous distention (JVD) with clear lung sounds
§ Elevated CVP
§ Narrowing pulse pressure
§ Decreased cardiac output
§ Muffled heart sounds
○ Medication therapy
§ Analgesics for pain
§ NSAIDs followed by steroids if inflammation doesn't respond to NSAIDs
§ Avoid anticoagulats because of tamponade
○ Client Ed
§ Explanation of inflammatory process to reduce anxiety
§ Take food, milk, or antacids with anti-inflammatory meds to reduce gastric distress

Front 2

ATHEROSCLEROSIS
Local accumulation of lipid and fibrous tissue along intimal layer of an artery

ENDARTERECTOMY
Opening of artery and removal of obstructing plaque

HOMAN'S SIGN
Pain on dorsiflexion of foot when leg is raised

INTERMITTENT CLAUDICATION
Ischemic muscle pain precipitated by a predictable amount of exercise and relieved by rest

KOROTKOFF SOUNDS
Sounds heard in auscultation of blood pressure

NEUROVASCULAR STATUS
Color, motion, sensation, temperature, and presence of distal peripheral pulses

ORTHOSTATIC HYPOTENSION
A drop in systolic blood pressure of 10 to 20 mmHg with upright posture

POIKILOTHERMIA
Body temperature that varies with environment

REST PAIN
Pain while resting that may even awaken client at night; pain is usually in distal portion of extremity (toes, arch, forefoot, heel) and is relieved when foot is placed in dependent position.

SYMPATHECTOMY
Surgical dissection of the nerve fibers that allows vasoconstriction to occur

VASODILATION
Widening of a blood vessel

OVERVIEW OF ANATOMY & PHYSIOLOGY
STRUCTURE AND FUNCTION OF BLOOD VESSELS
CIRCULATION AND DYNAMICS OF BLOOD FLOW
BLOOD PRESSURE CONTROL

DIAGNOSTIC TESTS AND ASSESSMENTS
DOPPLER
PLETHYSMOGRAPHY
DIGITAL INTRAVENOUS ANGIOGRAPHY
VENOGRAPHY
ANGIOGRAPHY
ANKLE-BRACHIAL INDEX (ABI)
COMPUTED TOMOGRAPHY
MAGNETIC RESONANCE IMAGING (MRI)

COMMON NUR TECHNIQUES AND PROCEDURES-BP MEASUREMENT
• BP is primarily a function of cardiac output and systemic vascular resistance
• Arterial blood pressure = cardiac x systemic vascular resistance
• Proper technique
○ Client should not have smoked or ingested caffeine 30 min prior
○ Record systolic and diastolic sounds-known as Korotkoff sounds (the disappearance of sound is the diastolic reading)
○ Two or more readings separated by 2 min should be averaged

PRIMARY HYPERTENSION
Description-disorder characterized by bp that consistently exceeds 140/90 confirmed on at least two visits several weeks apart; onset is primarily in people 25-55; greatest occurrence is in African Americans
R/T-hypertension can be primary (essential ) or secondary: primary hypertension accounts for 90=05% of all cases; there is no known cause but risk factors include
Positive family history
High sodium intake
Obesity
Inactivity
Excessive alcohol intake
Assessment
Subjective
Reports of fatigue, nocturia, dyspnea on exertion, palpitation, angina, headaches, weight gain, edema, muscle cramps, or blurred vision; symptoms may be caused by target organ damage rather than the high blood pressure itself
Objective
bP consistently > 140 mmHg systolic and >90mmHg diastolic; prehypertension category of at risk population is systolic BP>130 or diastolic >85
Planning and Implementation
Inform client that hypertension is usually asymptomatic, and symptoms will not reliably indicate BP levels
Medication Therapy
Meds used include diuretics beta blockers, calcium channel blockers, angiotensin converting enzyme inhibitors (ACE) inhibitors, angiotensin II receptor blockers (ARBs) and vasodilators (see Table 4-1)
Client Ed
Lifestyle modifications
Sodium restriction
Weight reduction
DASH (dietary approaches to stop hypertension)
General med therapy and potential side effects
Supplement potassium if taking loop diuretics
Prevent orthostatic hypotension (a drop in blood pressure of 10 to 20 mmHg with upright posture( by rising out of the bed or chair slowly

PERIPHERAL ARTERIAL DISEASE
• Description-disorders that interrupt or impede arterial peripheral blood flow due to vessel compression, vasospasm, and/or structural defects in the vessel wall
• R/T-chronic arterial obstruction leads to inadequate oxgenation of the tissues causing intermittent claudication, which is ischemic muscle pain precipitated by a predictable amount of exercise and relieved by rest
• Assessment
Subjective
§ Cl reports aching, cramping, fatigue or weakness in the legs that is relieved by rest (claudication); this is an early indication of disease
Objective
§ Extremities may be cool & pale with a cyanotic color on elevation
§ Bruits may be auscultated
§ Peripheral pulses may be diminished or absent
§ Ulcers may be present on the lower extremities in areas affected by reduced circulation with deep pale base, demarcated edges, painful; treated with wet to moist saline dressings or surgical revascularization
• Planning & Implementation
○ Goal: adequate tissue perfusion
§ Encourage cl to stop smoking as nicotine causes vasoconstriction and hypercoagulability of of blood
§ Encourage cl to exercise and walk to the point of pain as this decreases claudication; explain to stop walking when pain occurs to decr oxygen needs to affected area and to resume when pain hasstopped in order to build tolerance to exercise and stimulate growth of collateral circulation
§ Teach cl to avoid restrictive clothing, including girdles, garters and socks
§ Keep feet warm and in a dependent position; do not elevate feet if pain is present
If surgery is indicated provide appr post op care
○ Angioplasty
§ Monitor neurvascular status (color, motion, sensitivity, temp, and presence of distal peripheral pulses) to the affected extremity every 15 min x 4, every 30 min x 4, then q 1-4 hr(s) after sheath removal
§ Maintain immobilization of affected extremity for at least 6 hrs by reminding client to keep extremity still or lightly immobilize ankle with sheet tucked under both sides of mattress
§ Maintain a pressure dressing and sand bag (or other occlusive device) at site
○ Bypass grafting
§ Assess for occlusion of graft by assessing for severe ischemic pain, loss of pulses, decreasing ankle-brachial index, numbness/tingling in extremity, coolness of the extremity
○ Endoarterectomy-same principle of care
Client Ed
○ Promote vasodilation: provide warmth (never by direct heat to the limb) and prevent long periods of exposure to cold; avoid use of restrictive clothing

ARTERIAL EMBOLISM
• Description-arterial emboli usually arise from thrombi that developed in the heart as a result of atrial fibrillation, myocardial infarction, prosthetic valves, or congestive heart failure
• Assessment the six P's
○ Pain
○ Pallor
○ Pulselessness
○ Parasthesias (altered local sensation)
○ Paralysis (weakness or inability to move extremities)
○ Poikilothermia (body temp that varies with environment)
• Planning & Implementation
○ Place affected extremity in a neutral position with no restrictive bedding/clothing; keep extremity warm
○ If necrosis is present, surgical treatment is required; an emergency embolectomy needs to be performed within 4-5 hours of embolism to prevent necrosis and permanent damage to the extremity

BUERGER'S DISEASE (THROMBOANGIITIS OBLITERANS)
• Description-an inflammatory disease of the small and medium sized veins and arteries accompanied by thrombi and sometimes vasospasm of arterial segments; may occur in upper or lower extremities but is most common in the leg or foot
• Assessment-
○ Since nerves are also inflamed, there may be severe pain and constriction of the small blood vessels controlled by them, rest pain is common
○ Ischemic ulcers and gangrene are common complications of progressive Buerger's disease
• Planning & Implementation
○ Arrest progress of disease by smoking cessation


RAYNAUD'S DISEASE
• Description-localized, intermittent episodes of vasoconstriction of small arteries of the hands and less commonly the feet, causing color and temp changes
• R/T-attacks are triggered by exposure to cold, emotional stress, caffeine ingestion and tobacco use
• Assessment-classic tri-phasic color changes (pallor, cyanosis, and rubor) in the hands with accompanying reduction in skin temperature
• Client Ed
○ Keep hands warm: wear gloves when out of doors, in air-conditioned environments or when handling cold food

AORTIC ANEURYSM
Description-a localized dilation or outpouching of a weakened area in the aorta that is classified by region as thoracic or abdominal or as dissecting
R/T-half of all aneurysms greater than 6 cm in size will rupture within year
Assessment-dissecting aneurysms present with sudden, severe, and persistent pain described as 'tearing' or 'ripping' in the anterior chest or the back
Surgical care-
Preop the nurse marks and assesses all peripheral pulses for comparison postop
Postop
Graft occlusion
Hypovolemia/renal failure
Resp distress
Cardiac dysrhthymias
Paralytic ileus
Paraplegia/paralysis
Meds
Goal of nonsurgical management is to maintain blood pressure at a normal level to decrease the pressure on the arterial system and reduce the risk of rupture
Client Ed
How to self-manage anticoagulant therapy
For postop clients, teach routine postop care

THROMBOPHLEBITIS
Description-the formation of a thrombus (clot) in association with inflammation of the vein; classified as superficial or deep
Assessment
Subj
Obj-superficial & deep
Deep-if the calf is involved. Homan's sign may be present (pain on dorsiflexion of the foot, especially when the leg is raised)
Planning & Implementation
○ Provide for relief of pain
Assess pain on a scale of 1 - 10
Elevate affected leg higher than the heart to promote venous drainage
Provide analgesics as ordered
○ Decrease edema
Apply warm, moist compresses intermittent or cont to affected extremity
○ Prevent pulmonary emboli
Never massage affected extremity
Instr client to report any pink-tinged sputum and monitor for tachypnea, tachycardia, shortness of breath, chest pain, and apprehension, which may indicate a pulmonary embolism

VENOUS INSUFFICIENCY
Description-inadequate venous return over a long period of time that causes pathologic changes as a result of ischemia in the vasculature, skin, and supporting tissues
Assessment
Objective-
§ Edema of the lower legs, may extend to the knee
§ Thick, coarse, brownish skin around the ankles ("gaiter" area) and feet
§ Stasis ulcers, usually in the malleolar area (ruddy base, uneven edges)
Planning & Implementation
Increase venous blood return, decrease venous pressure
○ Bedrest
○ Keep legs elevated above heart level
○ Avoid long periods of standing
○ Wear elastic support or compression stockings
Treat venous stasis ulcers
Open lesions are treated with a hydrocolloid dressing and compression wraps; a topical ointment, such as low-dose hydrocortisone, zinc oxide, or an antifungal may also be indicated
Client Ed
○ Elevate legs for at least 20 min four times a day
○ Keep legs above level of heart when in bed

VARICOSE VEINS
Description-a vein or veins in which blood has pooled, producing distended tortuous, and palpable vessels
Assessment
Subjective-
§ client may complain of aching, heaviness, itching, swelling, and unsightly appearance to legs
Objective-
§ dilated, tortuous superficial veins will be seen along the upper and lower leg
§ Superficial inflammation may develop along path of the varicose vein
§ Positive Trendelenburg test (done to evaluate valve competence)
□ Client is placed in supine position with elevated legs
Planning & Implementation
○ Improve venous circulation
§ Assess pulses and neurovascular status of lower extremities
○ Vein ligation surgery involves ligation (tying off) of the entire vein (usually saphenous) and dissection and removal of the incompetent tributaries
§ Perform hourly circulation checks postop
§ Elevate extremity to a 15-degree angle to prevent stasis and edema
§ Apply compression gradient stockings from foot to groin

Back 2

AGNOSIA
Inability to recognize familiar subjects; agnosia may be visual, auditory, or tactile

APHASIA
A language disorder

APRAXIA
Inability to carry out motor pattern (ie, drawing a figure, getting dressed) even with strength and coordination

AUTONOMIC DYSREFLEXIA
An exaggerated sympathetic response that occurs in clients with T-6 injuries or above; response is seen after spinal shock occurs when stimuli cannot ascend the cord, a stimulus such as urge to void or abdominal discomfort triggers massive vasoconstriction below injury, vasodilation above injury, and bradycardia

BRADYKINESIA
Slow movements caused by muscle rigidity

BROCA'S AREA
Motor control of speech in the temporal lobe of the dominant hemisphere

DYSARTHRIA
Defective articulation of speech

DYSPHAGIA
Difficulty swallowing

HEMIANOPSIA
Loss of half of visual field in one or both eyes

INTRATHECAL
Through thecal of spinal cord into subarachnoid space

PARAPLEGIA
Paralysis of lower extremities

TETRAPLEGIA
Formerly called quadriplegia, is paralysis of arms, trunk, legs, and pelvis

WERNICKE'S AREA
Section of temporal lobe responsible for primary auditory reception area and auditory association areas of speech

OVERVIEW OF ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM

BASIC STRUCTURE AND FUNCTION OF CELLS IN THE NERVOUS SYSTEM
• CENTRAL NERVOUS SYSTEM
○ BROCA'S AREA
○ WERNICKE'S AREA
• PERIPHERAL NERVOUS SYSTEM
• BLOOD SUPPLY
• BLOOD-BRAIN BARRIER
• PROTECTIVE STRUCTURES

DX TESTS & ASSESSMENTS OF NERVOUS SYSTEM
ASSESSMENT OF NERVOUS SYSTEM
Assess chief complaints
A- any associated symptoms with chief complaint
P-what provokes (makes worse) or palliates (makes better) symptoms
Q-quality of symptoms
R-region & radiation
S-severity of symptom on a scale of 1-10
T-timing-when did it stop and start-intermittent or constant-duration
Physical assessment
Mental status
□ Orientation to person, place, time, appearance, behavior, mood, speech pattern, and thought & perception including insight, thought, content, and judgment
□ Client-awake, alert, able to understand and respond to questions
□ Cl with altered LOC may have range of behaviors; terms used to describe this range from confused to comatose
□ Acute confusion or delirium should be recognized and treated by eliminating the cause; try to avoid confusing delirium with dementia (chronic problem
Cranial nerves-assessment of cranial nerves can be performed-see Table 5-3
Motor function
□ Body muscles for size, tone, movement & strength
□ Compare left and right side for symmetry and equality
□ Assess for tremors (rhythmic movements) and fasciculations (twitching)
□ Criteria for grading muscle strength
§ Cerebellar exam-balance and coordination are under control of the cerebellum
□ Assess gait, have client walk normally and then on heels and toes and assess coordination; perform a Romberg's test by having the client stand with feet together and eyes closed while you stand close by to prevent falling; minimal swaying
Assess coordination, observe client's ability to touch own nose and then touch one of your fingers, then his or her nose again, next observe the client's ability to touch each finger to the thumb
§ Reflexes
□ Babinski reflex is assessed by stroking lateral aspect of sole of foot from heel to ball, curving medially in the ball; its presence is noted with dorsiflexion of the big toe and fanning of the other toes, and is considered normal in infants but abnormal in adults; in adults, the normal response is curling of the toes (called a negative Babinski)
§ Speech
□ Dysarthria-ineffective articulation of speech; may be motor deficit of tongue and speech muscles
□ Aphasia-a language disorder that is classified by type
® Expressive-motor or nonfluent aphasia-called Broca's aphasia; inability to express oneself using motor aspects of speech
® Receptive-fluent or sensory aphasia-called Wernicke's aphasia-inability to comprehend spoken words
® Global aphasia-cl can neither express nor comprehend language (mixed receptive and expressive)

DX STUDIES OF NERVOUS SYSTEM
• Cerebrospinal fluid analysis CSF is collected for analysis via lumbar puncture (LP); CSF is studied for color, clarity, glucose, protein, blood, white cells, and bacteria
• Radiological studies
○ Cerebral angiography
○ Computed tomography (CT)
○ Magnetic resonance imaging (MRI)
• Electrographic studies
○ Electroencephalography (EEG) a dx procedure that measures brain waves with multiple scalp electrodes that is then interpreted by neurologic patterns of brain waves
○ Electromyography (EMG) and nerve conduction studies; these tests are used to differentiate between peripheral nerve and muscle disorders


ACUTE DISORDERS OF THE NERVOUS SYSTEM
ALTERED LEVEL OF CONSCIOUSNESS (LOC)
• Description-an altered LOC is a change in arousal or alertness and/or a change in cognition or solving complex problems (thought processes, memory, perception, problem solving, and emotion): it is often the first sign of a change in neurologic status
• Assessment
○ Confusion, forgetfulness, disorientation to time, then person, then place, agitation, poor problem solving abilities, or any change in behavior may be an early change in cerebral function
○ Changes to lethargy, obtundations, and stupor result from greater cerebral deterioration
○ A change from purposeful movements to decorticate posturing, small restrictive pupils, and positive doll's eyes manifest midbrain deterioration
○ Decerebrate posturing fixed pupils and positive cold caloric tests show deterioration at the level of the pons
• PLANNING & IMPLEMENTATIONS
○ Assess for ability to clear secretions assess breath sounds; maintain patent airway in the unconscious client; maintain client with ineffective airway in side-lying positon;provide tracheostomy care q 4 hrs if client has one
○ Assess swallow and gag reflex; provide intervention to prevent aspiration (side-lying head of bed at 30 degrees) monitor for and report possible aspirations

INCREASED INTRACRANIAL PRESSURE (ICP)
• Description-
○ increased ICP is defined as a prolonged pressure greater that 15 mmHg (normal 5-10 mmHg) measured in the lateral ventricles
○ Coughing, sneeaing, straining, and bending forward cause a transient increase in ICP that does not cause significant tissue ischemia
○ Cushing's triad/response: involves three classic signs or responses to increased ICP; incr systolic blood pressure while diastolic remains the same, widening pulse pressure, and reflex bradycardia from stimulation of the carotid bodies
• Assessment
○ Clinical manifestations: the earliest signs of ICP may be blurred vision, decreased visual acuity, and diplopia because of pressure on the visual pathways; headache, papilledema, or swelling of the optic disk and vomiting are the next sign; the most significant sign of increased ICP is a change in LOC; as pressure increases from front to back of the brain, the LOC deteriorates
○ DX & lab tests
§ Lab tests are performed to augment and monitor treatment approaches; serum osmolarity monitors hydration status and ABGs measure pH, oxygen, and carbon dioxide (hydrogen ions and carbon dioxide are vasodilators that can increase ICP)
• Planning & Implementation
○ Assess neuro status every 1-2 rs and report any deterioration in assessment areas-
○ Maintain airway
○ Assess for bladder distention and bowel constipation
○ Plan nursing care so it is not clustered
○ Maintain fluid restriction
○ Keep dressings over catheter dry and change dressings as prescribed
• Med Therapy
○ Osmotic diuretics such as mannitol (Osmitrol) and loop diuretics such as furosemide (Lasix) are mainstays used to decrease ICP; they work by drawing water from edematous tissues and into vascular system; they can also disturb glucose and electrolytes so it is necessary to monitor their effect
• Client Ed
○ Teach client at risk for increased ICP to avoid coughing, blowing the nose, straining for bowel movements, pushing against the bed side rails or performing isometric exercises (or any other activity that closes the glottis)
○ Advise the client to maintain neutral head and neck alignment


HEAD TRAUMA & SKULL FRACTURES
Description-
○ skull fracture is a break in the skull that occurs with or without intracranial trauma; the force of the impact significantly increases the risk of hematoma formation; the disruption of the skull can lead to infection and cranial nerve injury
Assessment-
○ Clinical manifestation associated with skull fractures may give clues to area of fracture; basilar skull fracture may produce the following manifestations
§ Battle's sign, ecchymosis over mastoid process
§ Hemotympanium, blood visible behind the tympanic membrane
§ Raccoon eyes, bilateral periorbital ecchymosis
§ Rhinorrhea (CSF leakage through nose)
§ Otorrhea (CSF leakage through ear)
• Planning & Implementation
○ O bserve client for otorrhea or rhinorrhea
○ Test clear ear drainage and sinus drainage for glucose; only CSF has glucose; mucous secretions do not
○ Observe blood tinged drainage for halo sign; glucose-containing CSF dries in concentric rings on gauze or tissues
○ Keep nasopharynx and external ear clean; use sterile technique and supplies when cleaning drainage from nose and/or ears
○ Instruct client not to blow nose, cough, or inhibit sneeze and to sneeze through an open mouth
• Client Ed
○ Instruct client and family to go to ER if client experiences drowsiness or confusion, difficulty waking, vomiting, blurred vision, slurred speech, prolonged headache, blood or clear fluid leaking from ears or nose, weakness in an arm or leg, stiff neck or seizures

HEAD TRAUMA INTRACRANIAL HEMORRHAGE
• DESCRIPTION-Intracranial hemorrhage is an escape of blood into the cranium, most commonly associated with blunt trauma; hemorrhage may cause a very slow to very rapid neurological deterioration
• R/T-intracranial hemorrhage results directly from trauma or from the shearing forces on cerebral arteries and veins from acceleration-deceleration injuries; they are classified by location
○ EPIDURAL HEMATOMA
○ SUBDURAL HEMATOMA
○ INTRACEREBRAL HEMORRHAGE
• Assessment
○ Clinical
§ Epidural hematoma-client may initially lose consciousness then have a short period of lucidness, followed rapidly by deterioration from drowsiness to coma
§ Subdural hematoma-manifestations may develop slowly and may be mistaken for dementia in the elder client
○ Planning & Implementation
§ Assess neurological signs on a regular schedule; clear the client's nose and mouth of secretions; suction airway as needed

INFLAMMATORY CONDITIONS: MENINGITIS
• Description-an inflammation of the meninges of the brain and spinal cord; besides infestious disease exposure, risk factors include basilar skull fracture, otitis media, sinusitis, mastoiditis, neurosurgery or other invasive procedures, systemic sepsis, and impaired immune function
• R/T-most freq cause is infection of the meninges and CSF (rarely chemicals are the cause); infection (bacterial, viral, fungal or parasitic) causes an inflammatory response in the meninges
• Assessment-
○ Clinical-restlessness, agitation, & irritability
○ Signs of meningeal irritation, nuchal rigidity (stiff neck), positive Brudzinski's sign (pain, resistance, and hip & knee flexion occur when the neck is flexed to the chest while lying supine) and positive Kernig's sign (pain and/or resitance occurs with flexion of the knee… photophobia
○ Confusion, altered LOC
• Planning & Implementation
○ Assess neurological status and vital signs (with temp) regularly
○ Assess & report changes in neuro status or presence of cranial nerve dysfunction

GULLAIN-BARRE SYNDROME
• Description-an acute, rapidly progressive inflammationo f peripheral motor and sensory nerves characterized by motor weakness and paralysis that ascends from lower extremities in a majority of cases
• R/T-occurs most freq betw ages of 30 & 50; etiology is unknown
• Assessment-clinical manifestations
○ Weakness/paresis or partial paralysis progressing upward from lower extremities (paralysis in Guillain-Barre is ground to the brain
○ Paresthesias (numbness & tingling) and pain
• Planning & Implementation
○ Monitor cardiac status-hr, bp, dysrhytmias
○ Maintain adequate nutr as appr administer central or parenteral nutrition as needed
○ Prevent complications of immobility; encourage use of weak extremities

CEREBROVASCULAR ACCIDENT (CVA, BRAIN ATTACK, STROKE)
• Description-a CVA is a condition where neurological deficits occur as a result of decreased blood flow to a localized area of the brain; hypertension, diabetes mellitus, sickle cell disease, substance abuse, atrial fibrillation, and atherosclerosis are risk factors for stroke; onset of stroke may be rapid or gradual
• R/T-ischemia followed by cell death is the result of severe and prolonged cerebral blood flow obstruction
• Assessments-clinical manifestations vary according to cerebral vessel involved
○ Internal carotid-contralateral motor and sensory deficits of the arm, leg and face...
§ Aphasia-loss of ability to use language
§ Apraxia-inability to perform known tasks
§ Agnosia-inability to recognize
§ Hemianopsia-loss of one-half of the visual field in each eye
○ Vertebral artery-pain in face, nose or eye, numbness or weakness of face on ipsilateral side, problems with gait, dysphagia (difficulty swallowing)
• Therapeutic management
○ Durg therapy is the most common treatment for CVA, if it is a thrombotic stroke, meds could include thrombolytics and/or heparin
○ It is imperative not to disrupt a clot that has formed following hemorrhagic CVA
○ Resume diet orally only after successfully completing a swallowing evalutaion; clients may need thickened liquids, foods with consistency of oatmeal or nectar, and to chew on unaffected side of mouth; this is sometimes referred to as a dysphagia diet
○ Teach client with homonymous hemianopsia to overcome the deficit by turning the head side to side to be able to fully scan the visual field
• Med Therapy
○ Antiplatelet agents are used to treat TIAs and clients with previous CVA (except hemorrhagic CVAs)
○ During the acute phase of thrombotic and embolic stroke, thrombolytic therapy using tissue plasminogen activator may be administered within 3 hours to dissolve the clot


SPINAL CORD TRAUMA
• Description-
○ Spinal cord injuries are usually due to trauma; young adults and adolsescents are most commonly affected
• R/T-hyperflexion compresses vertebral bodies and disrupts ligaments and discs
• Assessment
○ Clinical manifestations
§ Spinal Shock, the temporary loss of reflex function, may occur following a spinal cord injury; symptoms include bradycardia, hypotension, flaccid paralysis of skeletal muscles, loss of pain, touch, temperature, pressure, visceral and somatic sensations, bowel and bladder dysfunction, and loss of ability to perspire, spinal shock has resolved once spinal reflexes return
§ Autonomic dysreflexia (also called autonomic hyperreflexia) is an exaggerated sympathetic response that occurs in clients with T6 injuries or higher; the response is seen after spinal shock occurs when stimuli cannot ascend the cord; a stimulus such as the urge to void or abdominal discomfort triggers massive vasoconstriction below the injury, vasodilation above the injury, and bradycardia
• Therapeutic Management
○ Acute management of spinal cord injuries, involves immobilizing injury and treating complications of resp distress, atonic bladder, paralytic ileus, and CV alterations; high-dose steroid protocol is initiated to prevent secondary cord injury from edema and ischemia; stabilization with devices such as halo traction and Gardner-Wells tongs or surgery is done when indicated
• Planning & Implementation
○ Treat autonomic dysreflexia immediately
§ Elevate head of bed and remove TEDS
§ Assess BP every 2-3 min while assessing for causative stimulus, remove the stimulus immediately when found (such as empty bladder, remove fecal impaction, or offending mechanical or thermal stimulus)
• Client Ed
○ Teach client and family to promote independence in self-care, such as self-catheterization technique, bowel evacuation, activities of daily living, etc
○ If client has a halo vest, teach that it raises the center of gravity; avoid bending over to reduce risk of falls; neck is immobilized in midline so client needs to learn to turn entire body to scan environment
• ASSESSMENT
PARAPLEGIA-is paralysis of the lower portion of the body; it occurs when the injury level is in the thoracic spine or lower
TRETRAPLEGIA-formally quadriplegia, is paralysis of the arms, trunk, legs, pelvic portion; it occurs when the level of injury is in the cervical spine
AUTONOMIC DYSREFLEXIA-(also called autonomic hyperreflexia) is an exaggerated sympathetic response that occurs in clients with T6 injuries or higher; the response is seen after spinal shock occurs when stimuli cannot ascend the cord; a stimulus such as the urge to void or abdominal discomfort triggers massive vasoconstriction below the injury, vasodilation above the injury, and bradycardia
• THERAPEUTIC MANAGEMENT-acute management of spinal cord injuries involve immobilizing injury and treating complications of respiratory distress, atomic bladder, paralytic ileus, and CV alterations; high-dose steroid protocol is initiated to prevent secondary cord injury from edema and ischemia; stabilization with devices such as halo traction and Gardner-Wells tongs or surgery is done when indicated
• PLANNING & IMPLEMENTATION
○ Treat autonomic dysreflexia immediately
§ Elevate head of bed and remove TEDS
§ Assess BP every 2-3 min while assessing for causative stimulus; remove the stimulus immediately when found (such as empty bladder remove fecal impaction, or offending mechanical or thermal stimulus)
• CLIENT ED
○ Teach client and family to promote independence in self-care, such as self-catheterization technique, bowel evacuation, activities of daily living, etc
○ If client has a halo vest, teach that it raises the center of gravity; avoid bending over to reduce risk of falls; neck is immobilized in midline so client needs to learn to turn entire body to scan environment driving is prohibited; food is cut into small pieces, and a straw is used liquids

CHRONIC DISORDERS OF NERVOUS SYSTEM

• SEIZURES
• Description-a seizure is an episode of excessive and abnormal electrical activity of all or part of the brain
• R/T-exact initiating factor for seizures is unknown
• Assessment-clinical manifestations
○ Simple partial seizures are limited to one hemisphere
○ Complex partial seizures originate in the temporal lobe and may be preceded by an aura
○ Generalized partial seizure is a partial seizure that has spread to both hemispheres and deeper structure of the brain
○ Tonic clonic seizures (grand mal) are most common type of seizure
○ Staus epilepticus is a life-threatening emergency that can occur during seizure activity
• Planning & Implementation
○ Provide intervention during seizures to maintain airway patency; turn client to side if needed to maintain airway and promote drainage of secretions without aspiration; have oxygen and suction equipment at the bedside for use following a seizure if needed; do not try to force an object, such as a bite stick, into the mouth of a client who is seizing, as this may break teeth or cause other injury
○ Provide intervention during a seizure to reduce the risk of injury; do not restrain client but provide an environment that will not create further injury
○ Document seizure actitivity promptly and report it as appropriate
• Med Therapy
○ Some commonly used antiepileptics are phenytoin (Dilantin), divalproex sodium (Depakote), valproic acid (Depakene), carbamazepine (Tegretol), gabapentin (Neurontin), and lamotrigine (Lamictal)
• Client Ed
○ Emphasize aura alert
○ Stress the importance of avoiding physical and emotional stress

PARKINSON'S DISEASE (PD)
• Description-parkinson's disease is a progressive, degenerative neurological disease characterized by bradykinesia, muscle rigidity, and nonintentional tremor, it affects older adults most often with a mean incidence of 60 years of age, it affects men more than women
• R/T-in PD, atrophy occurs in the substantia nigra that produces the neurotransmitter dopamine; as dopamine decreases, acetylcholine is no longer inhibited; this imbalance in neurotransmitter is the clinical basis for symptoms
• Assessments
○ BRADYKINESIA is slow movements caused by muscle rigidity; they affect also the eyes, mouth, and voice; there is also a staring gaze
○ Short-stepped, shuffling, and propulsive gait, which leads to increased risk of falls
○ Postural disturbanc, trunk tilted forward
○ Seborrhea
• Med Therapy
○ Drugs used to treat PD include monoamine oxidase (MAO) inhibitors, dopaminergics, dopamine agonists, and anticholinergics to treat PD; eventually all these drugs lose effectiveness; the fluctuating response to drugs is called the on-off response; antidepressants, especialy amitriptyline, are used to treat depression; propranolol may be used to treat tremors
• Client Ed
○ Gait training and exercises for improving ambulation, swallowing, speech and self-care

MULTIPLE SCLEROSIS
• Description-a chronic disorder of the CNS where the myelin and nerve axons in the brain and spinal cord are destroyed; there are four forms based on the rate of progression: benign relapsing remitting, primary progressive and secondary progressive
• R/T-unknown etiology possibly an autoimmune or genetic basis or may be caused by childhood viral infections
• Assessment
○ Clinical manifestations-visual disturbances or blindness (retrobulbar neuritis); sudden, progressive weaknessof one or more limbs; spasticity of muscles; nystagmus; tremors; gait instability; fatigue; bladder dysfunction (UTIs incontinence); depression
○ Dx and lab findings: lumbarpuncture for CSF (clonal IgG bands present): MRI, CT scans, muscle testing show characteristic changes
• Planning & Implementation
○ Overall goal of care is to maintain as much independent function as possible
○ Include rest periods to prevent fatigue in the client, which is an exacerbating factor
○ Assist client with ADLs on an as-needed basis, provide adaptive utensils or other assistive devices as needed
○ Avoid sources of infection; illness can ct as a stressor and trigger an exacerbation
• Med Therapy
○ Immunosuppressant therapy, antiviral drugs, corticosteroids, antibiotics for urinary tract infections, interferon-alph, glatiramer (Copaxone), anticholinergic drugs, and antispasmodics


MYASTHENIA GRAVIS
• Description-a chronic progressive disorder of the peripheral nervous system affecting transmission of nerve impulses to voluntary muscles; causes muscle weakness and fatigue that increases with exertion and improves with rest; eventually leads to fatigue without relief from rest
• R/T
○ Causes include unknown etiology, family hx of autoimmune disorders, thyroid tumors
○ Onset is usually slow but can be precipitated by emotional stress, hormonal disturbances (pregnancy, menses, thyroid disorders), infections,
• Assessments
○ Clinical
○ Mild diplopia (double vison) and unilateral ptosis (eyelid dropping) caused by weakness in the extraocular muscles, weakness may also involve the face, jaw, neck and hip
○ Myasthenic crisis; sudden motor weakness; risk of respiratory failure and aspiration; most often caused by insufficient dose of med or an infection
○ Cholinergic crisis; severe muscle weakness caused by overmedications, also cramps, diarrhea, bradycardia, and bronchial spasm with increased pulmonary secretions and risk of respiratory compromise
○ Dx and Labs
○ Confirmation of the clinical dx can be made by IV adminstration of edrophonium chloride (Tensilon), which allows voluntary muscle contraction; Tensilon allows acetylcholine to bind with its receptors, which temporarily improves symptoms; weakness returns after the effects of Tensilon are discontinued; a positive Tensilon test confirms dx of myasthenia gravis
• Therapeutic Management
○ Focuses on med management with anticholinesterases; neostigmine (Prostigmin), pryidostigmine (Mestinon); immunosuppressants: corticosteroids, azathioprine (Imuran), and cyclosporine (Cytoxan); anti-inflammatory drugs; thymectomy (removal of the thymus gland); plasmapheresis-removes IgG (antiacetylcholine) antibodies, atropine sulfate (Atropine) for cholinergic crisis
○ Monitor meals and teach client to bend head slightly forward while eating/drinking to improve swallowing
○ Provide adequate nutrition: schedule meds 30-45 min before eating for peak muscle strength while eating
• Client Ed
○ Avoid extremes of hot and cold, exposure to infections, emotional stress and meds that may worsen or precipitate an exacerbation (alcohol, sedatives, local anesthetics)

ALZHEIMER'S DISEASE
• Description-alzheimer's disease (AD) is a progressive dementia with irreversible deterioration of general intellectual function; it affects adults in middle to late life; AD incidence increases with age
• R/T-the cause of AD is unknown; chemical changes in the brain are found in the hippocampus, and frontal and temporal lobes of the cerebral cortex
• Therapeutic Management
○ AD clients and their families require extensive follow-up and support because there is no cure for AD, the main objective of care si to match function with environment; safety and least restrictive environment are high priorities
• Planning & Implementation
○ Label room, drawers, or other items as needed
○ Orient client to person, place, and time as needed
○ Keep daily routine, consistent as possible

CRANIAL NERVE DISORDERS
• Description-cranial nerve (CN) disorders involve dysfunctiono f the cranial nerves, the most commonly affected are the trigeminal nerve (CNV) and the facial nerve (CN VII); trigeminal neuralgia and Bell's Palsy are the respective disorders
• R/T-trigeminal neuralgia has an unknown cause
• Bell's Palsy also has an unknown cause-inflammation of the nerve and a viral cause has been suggested
• Therapeutic Management
○ Trigeminal neuralgia treatment is centered on controlling pain with antiepileptic meds such as carbamazepins (Tegretol)
○ Bell's palsy-the only medical treatment that influences outcome is administration of corticosteroids, but their use has been questioned; antiviral medication is also currently very popular, as well as gentle massage stimulation
• Planning & Implementation
○ Encourage client to chew on unaffected side
○ Protect cornea with artificial tears, sunglasses, eye patch at night and gentle intermittent closure of eye
• Med Therapy
○ Trigeminal neuralgia: the most useful drug for controlling pain is carbamzepine (Tegretol); when this is not effective, phenytoin (Dilantin) is tried