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45 Cards in this Set
- Front
- Back
Cognitive Impairment
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Term that describes a range of disturbances in cognitive functioning, including disturbances in memory, orientation, attention, and concentration.
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Confusion
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Broad and imprecise term that conveys little meaning (it is a symptom of a medical condition).
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Dementia
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1. It is an umbrella to describe a number of diseases that impair cognition
2. Progresses over a period of years, but can be abrupt 3. Affects memory, orientation, language, judgment, visuospatial skills, concentration, and the ability to sequence tasks 4. Not reversible |
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Types of Dementia
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1. Alzheimer’s Disease (most common 60%)
2. Primary Causes: Diffuse Lewy body dementia (15-25%), vascular dementia (10%), Alzeheimer’s disease, Multiinfarct (post-stroke), Creutzfledt-Jakob Disease (rare) 3. Secondary Causes: Parkinson’s Dementia, AIDS dementia, ETOH abuse, postanoxic encephalopathy, head injury 4. Many more—but rare |
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Key features of dementia
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1. Changes in memory
2. Increased forgetfulness 3. Decreased ability to perform ADL’s 4. Alterations in communication 5. Inability to make decisions 6. Decreased attention span |
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Key features of advanced stages of dementia
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1. Aggressiveness
2. Rapid mood swings 3. Increased confusion at night (sundowners) 4. Fatigue 5. Wandering 6. Hoarding 7. Paranoia 8. Depression |
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Normal Aging vs. Early Signs of Alzheimer’s
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1. Forgetting the names of people you rarely see VS. Forgetting the names of people close to you
2. Briefly forgetting part of an experience VS. Forgetting a recent experience 3. Occasionally not being able to find something VS. Not being able to find important things 4. Mood changes because of an appropriate cause VS. Having unpredictable mood changes 5. Changes in your interests VS. An increased loss of outside interests |
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What are the basic assessments for dementia?
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1. Mini Mental State Exam (MMSE)
2. SET test |
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What is the Mini Mental State Exam (MMSE)?
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1. Orientation
2. Registration 3. Attention and Calculation 4. Recall 5. Speech and Language |
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What is the SET test?
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Name 10 items from 4 categories (fruits, animals, colors, towns) --- (FACTs)
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Diagnosis of Dementia
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1. Autopsy
2. Rule out other illnesses a. CBC b. Electrolytes, BUN, glucose c. B12 levels d. Folate (B9) levels e. Thyroid and liver function tests f. Drug toxicity tests g. Alcohol screening 3. CT scan- brain atrophy + other brain changes 4. PET scan- decrease metabolic activity in the brain 5. MRI- rule out other causes of neuro disease 6. EEG- slows changes |
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The older client states that he has recently noted changes in his cognition and worries he is developing Alzheimer’s disease. The nurse suspects the client is not experiencing Alzheimer’s symptoms because he:
a. is also experiencing hallucinations. b. has only mild memory loss. c. has recently been placed on a medication regimen that could affect cognition. d. is not experiencing changes in his eyesight. |
c. has recently been placed on a medication regimen that could affect cognition.
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Planning care for patients with Dementia
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1. Individualized for patient/Don’t ASSUME
2. Basic Nutrition 3. Deal w/ agitation 4. Check if r/t to pt comfort 5. Diversion activity 6. Pharmacological management “start slow” remember half-life 7. Communication 8. Reality Orientation 9. Calming, caring atmosphere 10. Dependable routines 11. Simple words; brief and consistent 12. Consistent caregivers 13. Communication board 14. Connect present w/ past experiences 15. Environment reminders (pictures, etc…) 16. Non-pharmacologic a. Don’t overstimulate b. Calming for the patient 17. Restlessness and Wandering a. Safe Return Program b. Frequent walks c. Keep busy d. Minimize restraints |
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Parkinson's disease
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PD-3rd most common neurological disorder of older adults—effects motor ability
Incidence 40-70 (peak onset at 60) y/o <40 y/o rare |
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Cardinal symptoms of Parkinson's disease
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1. Rest tremor of a limb (shaking with the limb at rest)
2. Slowness of movement (bradykinesia) 3. Rigidity (stiffness, increased resistance to passive movement) of the limbs or trunk 4. Poor balance (postural instability) |
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Pathophysiology of Parkinson's Disease
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1. Atrophy occurs in the substantia nigra that produces neurotransmitter—dopamine
2. Dopamine DECREASES, acetycholine (Ach) no longer inhibited, this imbalance produces symptoms 3. Also causes autonomic nervous system s/s— INCREASED perspiration, orthostatic hypotension |
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Clinical manifestations of Parkinson's Disease
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1. Begins subtly—fatigue & slight resting tremor.
2. Bradykinesia, slow movements caused by muscle rigidity, effects eyes, mouth, & voice 3. Uncoordinated movements short-stepped, shuffling, propulsive gait 4. Postural disturbance 5. Seborrhea 6. Excess sweating face & neck- on trunk & extremities 7. Anxiety & depression 8. Sleep disturbances 9. Dysphagia 10. Chewing and swallowing difficulties |
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What is typical of clients with Parkinson's disease?
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The masklike facial expression typical of clients with Parkinson disease
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Brain Attack/CVA/Stroke
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1. Medical emergency - 3rd most common cause of death in US; Primary cause of disability
2. Disruption of normal blood supply to the brain causing hypoxia to the tissues, ischemia, possible infarct! |
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Impaired Verbal Communication
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1. Left hemisphere stroke results in aphasia (in all but 15-20% of the population)
2. Types of Aphasia (ability to use or comprehend language) a. Expressive b. Broca’s or motor-difficulty in speaking & writing c. Receptive d. Wernicke’s, or sensory—difficulty understanding spoken words, written words, speech often meaningless (a new word w/ a new meaning for pt) e. Global (mixed) f. Combination of difficulty w/ words & speech. Difficulty w/ reading & writing. 3. Dysarthia: Due to loss of motor function of tongue or muscles of speech; Slurred speech 4. Right cerebral can have “left neglect”/“unilateral neglect”. If you stand on their “neglect side”—they will neglect YOU! 5. Also, don’t forget to think of previous impairments: Vision—need glasses; Hearing—place hearing aids |
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Seizures vs. Epilepsy
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1. Seizure (a s/s of Epilepsy)—abnormal, sudden, excessive discharge of electrical activity within the brain.
2. Epilepsy– chronic disorder with recurrent unprovoked sz activity. Caused by: Abnormality in electrical neurol activity; Imbalance of neurotransmitters (GABA); Or, combination of both |
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Pre-Seizure risk factors in epilepsy
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1. Increased Physical activity
2. Emotional stress 3. Excessive fatigue 4. Alcohol or caffeine consumption 5. Certain foods or chemicals |
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Causes of Seizures
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1. May be symptomatic of underlying disorder! 1st seizure pt <2 years of age
Causes—anoxia at birth, meningitis, hypoglycemia, hypocalcemia, fever, congenital defects 2. 1st seizure pt 35-60 y/o Causes—tumor, vascular disease, trauma, withdrawal ETOH, metabolic disorders, electrolyte imbalances, sedative-hypnotic drugs, heart disease, ALWAYS r/o tumor! |
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Partial (aka-focal/local) Seizures
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1. Limited # of neurons—in one section of the hemispheres
2. Simple partial: Maintain consciousness 3. Complex partial: Impairment of consciousness w/ automatisms 4. Partial seizures can evolve into generalized ones |
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Generalized Seizures
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Activation of neurons in both hemispheres
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Types of Generalized Seizures
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1. Tonic: Prolonged muscle contractions
2. Clonic : Muscle contracts alternate w/ rapid relaxation 3. Tonic-clonic: Combination of both 4. Absence: Impaired/diminished awareness, ability to respond, amnesia, or combination 5. Myoclonic: Sudden contraction of various muscle groups 6. Atonic: Sudden loss of postural muscle tone-bilateral |
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Phase 1 Assessment of Seizure
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Before the seizure:
Aura? What senses involved? What was the pt doing?, any particular event or activity? |
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Phase 2 Assessment of Seizure
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During the seizure:
Automatisms—lip smacking, pill rolling, tapping, swallowing, grimacing? Eyes rolled to back of head, remain center, left to right, pupils react to light? Diaphoretic, eryththematous, pallor? Incontinent of urine/feces? Apnea or cyanotic? Vital signs? |
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Phase 3 Assessment of Seizure
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After the seizure:
Patent airway VS How long lost consciousness? Paralysis, aphasia, Status Epilepticus = Another seizure, prior to recovery of 1st. Leads to respiratory arrest -> cardiac arrest, because of lack of O2 Behavior post seizure (postictal)—headache, confused, violent, doesn’t remember |
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Witnessed Seizure
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1. Stay w/ patient: Notify MD; Oxygen
2. Safety: Place on flat surface; If on floor—leave pt; Turn pt to side—if able Move items away—to prevent injury 3. Prepare for treatment/complications: Crash cart; Suction; Large bore IV (18g); Medication |
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Seizure medications during active seizure
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1. Lorazapam (Ativan) 2-4 mg IV over 2 minutes. May repeat up to 8 mg
2. Valium IV 10-20 mg IV. May repeat up to 20 mg. 3. D50W (glucose) via IV |
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Seizure medications during active seizure
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1. Lorazapam (Ativan) 2-4 mg IV over 2 minutes. May repeat up to 8 mg
2. Valium IV 10-20 mg IV. May repeat up to 20 mg. 3. D50W (glucose) via IV |
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Phenytoin
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1. Phenytoin (Dilantin)- for status epilepticus
2. Dose: 15mg/kg 3. IV infusion: Mix w/ 50 ml NS, 50mg/min via IV pump. Monitor IV site! 4. Monitor especially in cardiac pts 5. Monitor therapeutic levels q9-12h after loading dose; 10-20mcg/ml Phenytoin |
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Phenytoin
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1. Phenytoin (Dilantin)- for status epilepticus
2. Dose: 15mg/kg 3. IV infusion: Mix w/ 50 ml NS, 50mg/min via IV pump. Monitor IV site! 4. Monitor especially in cardiac pts 5. Monitor therapeutic levels q9-12h after loading dose; 10-20mcg/ml Phenytoin |
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Other seizure managements
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A. Phenytoin (Dilantin), fosphenytoin (Cerebryx)- Status epilepticus & all types except: absence, myoclonic, and atonic.
B. Tegretol— tonic-clonic, partial sz C. Phenobarbital—tonic-clonic, partial sz D. Neurontin—partial sz E. Depakote—partial sz, adjunct therapy for others |
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Other seizure managements
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A. Phenytoin (Dilantin), fosphenytoin (Cerebryx)- Status epilepticus & all types except: absence, myoclonic, and atonic.
B. Tegretol— tonic-clonic, partial sz C. Phenobarbital—tonic-clonic, partial sz D. Neurontin—partial sz E. Depakote—partial sz, adjunct therapy for others |
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After the seizure
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1. Turn on side
2. ABC’s 3. Suction airway 4. Vital signs + pulse ox + fsbs 5. Check for injuries 6. Explain to patient—when able to understand 7. Stay with patient—until A&O x 3 8. Document |
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After the seizure
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1. Turn on side
2. ABC’s 3. Suction airway 4. Vital signs + pulse ox + fsbs 5. Check for injuries 6. Explain to patient—when able to understand 7. Stay with patient—until A&O x 3 8. Document |
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Documentation of a seizure
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1. Pt activity, etc prior to seizure
2. Duration of seizure 3. Description of all involuntary behavior (incontinence, lip smacking, tonic movements, etc) 4. Interventions (O2, medications, etc) 5. Response of pt to interventions/seizures Post seizure mental status. If pt can recollect, their assessment prior to the seizure, aura, smells, etc. |
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Documentation of a seizure
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1. Pt activity, etc prior to seizure
2. Duration of seizure 3. Description of all involuntary behavior (incontinence, lip smacking, tonic movements, etc) 4. Interventions (O2, medications, etc) 5. Response of pt to interventions/seizures Post seizure mental status. If pt can recollect, their assessment prior to the seizure, aura, smells, etc. |
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Discharge Instructions for Seizure
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1. Medication regimen
2. Family instructions on during/post seizure care 3. Follow-up lab work. 4. MD appointments. 5. NO DRIVING! DMV notified by MD. 6. Alert band for recognition |
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Spinal Cord Injuries (SCI)
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1. Caused by excessive force to spinal cord & vertebral column: Fracture, dislocation, sublaxation; Penetrating trauma—gun shot, knife (24%)
2. Causes a. Trauma—45% MVA b. Falls (22%), sport injuries (8%) c. Disease—polio, tumor, spina bifida 3. Typical client a. Unmarried male (82%), 16-30 y/o, summer months, Caucasian, cervical injury |
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Frankel Classification Spinal Cord Injury
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1. Class A—complete injury
No motor or sensory function below the level of the injury 2. Class B—incomplete injury w/ preserved sensation only No motor function below, but sensory 3. Class C—incomplete injury w/ non-useful motor function Some motor function and may or may not have sensory function below the injury 4. Class D—incomplete injury with useful motor Voluntary, useful motor below level of injury 5. Class E—complete recovery Sensory and motor functions will return, although may still have abnormal reflexes or bowel, bladder, and sexual dysfunction |
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Autonomic Dysreflexia aka Hyperreflexia
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1. Affects pt’s with T6 or higher
2. Caused by: a noxious stimulus – distended bladder or constipation 3. S/s: Sudden severe HTN (can cause stroke), bradycardia, nausea, blurred vision, sudden severe HA, nasal stuffiness, and flushing above level of injury and diaphoresis and coolness below level of injury. |
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Autonomic Dysreflexia aka Hyperreflexia - Treatment
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1. Place pt in sitting position
2. Notify MD 3. Loosen tight clothing 4. Assess for and tx cause 5. Assess bladder (foley cath or distention) 6. Assess for impaction and tx 7. Check room temp 8. Monitor BP q 10-15 mins 9. Tx BP (nitrates) |