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Neurology
Alzheimer's Disease(and other things we need to cover)
Alzheimer’s Disease
AKA• AD• Primary degenerative
dementia• Senile dementia• Organic Brain Syndrome• Old timers disease
Pathophysiology
• Dementia– Characterized by an
uneven, downward decline in mental function
Pathophysiology
Alzheimer’s• Progressive• Irreversible• Degenerative neurologic
disease• Begins insidiously • Characterized by
– Gradual losses of cognitive function
– Disturbances in behavior & affect
Pathophysiology
• Physical changes o the cerebral cortex are visible under a microscope– Neurofibriallary tangles – Neuritic plaque– Decrease in brain size
Pathophysiology
• First affected– Cells that use Acetylcholine– Left side– Parietal & temporal lobes
Etiology
• Familial tendencies• Risk factor
– Age
• Men vs. women?– Equal
Clinical Manifestations
• Slowly progressive• Subtle• Age
– 85+
Clinical Manifestations
• 3 categories of Changes characteristic of dementia – – Cognitive– Functional– Behavioral
Clinical Manifestations
Stage 1- Early• Cognitive
– Forgetful– Subtle mild memory loss– attention span– Recent memory remote
memory
Clinical Manifestations
• Stage 1 – early• Functional
– Small difficulty in work (able to hide it)
– Mild anomia (cannot name objects)
– No motor deficits
Clinical Manifestations
Stage 1 – early• Behavioral
– Depression– Little interest in immediate
surroundings– Lack of spontaneity– Social behavior intact– Hide cognitive deficit
Stage 2 – Middle• Cognitive
– Obvious short term memory lapses
– Disoriented to time– Impaired judgment– Frequent loss of objects– Repeat the same story– Ability to think abstractly
disappears
Stage 2 – middle• Functional
– Hesitancy in verbal responses– Confabulation– Gets lost in familiar places– ability to handle money,
use phone
Stage 2 – middle• Behavior
– May try to hide memory problems
– Impulsive behavior– Hyperactive
Stage 3 – Late• Cognitive
– Disintegration of personality– Disorientation to person,
place and time– Confused– Agitation– Irritability– Paranoid delusions
Stage 3 – Late• Functional
– May forget to use objects correctly
– Dysarthria
Stage 3 – late• Behavioral
– Wandering– Restlessness– Pacing– Agitation– Disengages from activities &
relationships– Combative
Stage 3 – late• Behavioral
– Sundowning• Confused & restless after
dark• Want to go home• Less coping ability
Stage 4 – End Stage• Cognitive
– Terminal stage– Severe physical and mental
deterioration– No recognition of family or
self
Stage 4 – End stage• Functional
– Need total care for ADL’s– Incontinent– Loss of ability to
communicate– Loss of all voluntary activity– Swallowing problems
Review: Stage 1 (mild)
• Confusion and memory loss• Disorientation to time and place• Difficulty in performing routine tasks• Change in personality and judgment
Review: Stage 2 (moderate)
• Difficulty performing ADL’s• Anxiety• Suspiciousness• Agitation• Wandering• Pacing• Sleep disturbances• Difficulty recognizing family members
Review: Stage 3 (Severe)
• Loss of speech• Loss of appetite• Weight loss• Loss of B&B control• Total dependence on caregiver
Assessment & Diagnosis
• Hx & PE• Neuro tests• Autopsy• MRI
– Apparent changes
• Cognitive assessment scale
• Functional dementia scale
• Mini-Mental Status Exam– Disorientation – Cognitive impairment
Medical Management
• Exercise– anxiety & restlessness– PT
• Diet– Well balanced– Hydration
Medical Management
Rx• Cognex (tacrine Hydrochloride)
– Enhances acetylcholine uptake in the brain
– S/E/• Liver toxicity
• Aricept (donepezil)– cholinesterase inhibitor– Improves mental
function – by increasing the
amount acetylcholine
Nursing Management
Priority Nrs Dx.• Risk of injury• Anxiety• Communication• ADL• Alt. Nutrition
Nursing Management
• Sundowning– DC all non-essential meds– Check for pain– Light on– Exercise daily– No caffeine– Anti-depressants
– Having the patient sleep in a chair is better than no sleep at all
Nursing Management
Supporting Cognitive function• Calm, predictable environment• Limit environmental stimuli• Regular routine• Quiet pleasant manner of
speaking• Clear & simple explanations
Nursing Management
Supporting cognitive function
• Memory aids– Colanders– Pictures– Stop signs– Clocks– Instruction signs/notes– Pill organizer
Nursing Management
Promoting Physical safety• Move around freely• Remove hazards• Nightlights• Medications• Food• Smoking with supervision• Restraints?
– NO!
Nursing Management
Promoting Physical safety• Secure doors• Wear ID• Care at night• Shoes
• A client has been recently admitted with a medical diagnosis of dementia, Alzheimer’s type. When obtaining an assessment, the nurse should remember for safety purposes to ascertain what crucial information?
A. Sleep patterns and behaviorB. Skin turgorC. The degree of memory impairmentD. The level of distractibility
Nursing Management
Reducing anxiety & agitation• Uncluttered• Familiar• Low stimuli• Calm & hurried care• Music• Stroking• Rocking• Distraction
Nursing Management
Reducing anxiety• Validation therapy
– Enter their reality– Ask questions– Feelings – Distract
• Reality orientation• Structure activities• Avoid triggers
Nursing Management
Improving communication• Unhurried• noise• distractions• Clear & easy• List• Simple written • Non-verbal
Nursing Management
Promoting independence• Highest level of function• Clothing• Simple steps• Personal dignity• Choices• Dangerous activities
Nursing Management
Promoting Socialization & intimacy
• Visits Good– Short– Non-stress– 1 or 2 at a time
• Simple activities• Walking
Nursing Management
• Exercise• Pet therapy• Intimacy????
Nursing Management
Adequate nutrition• Calm & simple• Familiar foods• Look appetizing• Taste good• 1 food at a time• Small pieces
Nursing Management
• Finger foods• Food on the run• Watch hot food• Bibs?• Dental care
Nursing Management
Balance activity and Rest• Wandering• Assess sleep pattern• Day time
– Exercise– Regular patterns– Limit long naps
Nursing Management
• Sleep aid– Warm milk– Music– Back rub– Warm bath– Tea
Complications
• Malnutrition• Dehydration• Pneumonia• Pain
– Grimacing– Restlessness– Flexed position
Small Group Questions
• Damage to the brain in a patient with Alzheimer’s Disease occurs where?
• What memory is lost first in a patient with Alzheimer’s disease?
• Which neurotransmitter is associated with memory
• Given three nursing intervention for a patient with Alzheimer’s who is losing weight?
• A patient is confused and wandering. What intervention will best maintain safety?
• What about night time wandering?• A patient with Alzheimer’s occasionally she screams and
moans and annoys the other patients by repeating the same word over and over. The best approach for a solution to this behavior is for the nurses to do what?
• What medications are being used to treat AD?
• What activities are good for a patient who is confused or has short attention span?
• What are the priority nursing diagnosis for someone with AD?
• Give an example of confabulation• What is the biggest risk factor for AD?• When are AD patient most agitated?
Strategies to Minimize or Prevent Sundowning
• Make sure sundowning is not the result of physical illness or medication. • Caregivers need to be flexible in their approach and in their
expectations. • Avoid caffeine drinks in the afternoon and evening. • Have non-glare lighting. • Be soothing and try to be undemanding. Try to make the person with
Alzheimer's feel safe and secure.
• Make sure the person's physical needs are met, i.e. that they are not hungry, thirsty, or constipated.
• Avoid too many naps during the day. • Soothing music may help relax them. • Provide stimulating activities in the day without exhausting
the person. • Remember that a person with Alzheimer's does not have
control over their behavior
A 93 year-old female with a history of Alzheimer’s Disease gets admitted to an Alzheimer’s unit. The patient has exhibited signs of increased confusion and limited stability with gait. Moreover, the patient is refusing to use a w/c. Which of the following is the most appropriate course of action for the nurse?
A. Recommend the patient remain in her room at all times. B. Recommend family members bring pictures to the
patient’s room. C. Recommend a speech therapy consult to the doctor. D. Recommend the patient attempt to walk pushing the w/c
for safety.
• Fill in the blanks of the statement with the appropriate terms regarding the pathophysiology of a patient who has Alzheimer's disease: Researchers have identified two microscopic changes, ____ & ____, that occur in the brain of a patient with Alzheimer’s disease. These changes result in cortical atrophy.
A.Neuritic plaquesB.Neurofibrillay tanglesC. Nerve demyelinationD.Sclerotic plaquesE. Dysplasia
Cerebral Palsy
Pathophysiology• Non progressive• D/T cerebral anoxia
during birth• Results in CNS damage• No Cure!
Poliomyelitis
Pathophysiology• Virus• Mode of transmission
– Fecal-oral
Poliomyelitis
Clinical Manifestations• Cold-like symptoms• Pain & stiffness
– Back– Neck– Legs– Bulbar paralysis
Poliomyelitis
Prevention• VACCINE
– IPV• Inactive Polio Vaccine• Killed virus• Salk vaccine
– OPV• Oral polio Vaccine• Live vaccine• Can cause polio in some• Not used in USA
Poliomyelitis
Vaccination schedule• 2 months• 4 months• 6-18 months• Booster 4-6 years
The nurse is preparing to discharge a client with a long history of polio. The nurse should tell the client that:
A.Taking a hot bath will decrease stiffness and spasticity.
B.A schedule of strenuous exercise will improve muscle strength.
C. Rest periods should be scheduled throughout the day.
D.Visual disturbances can be corrected with prescription glasses.
Neurosyphilis
Pathophysiology• Bacteria• Mode of transmission
– STD
• Mucus membrane • Systemic • Lymph • Brain & Spinal cord
Neurosyphilis
• Tabes dorsalis =– posterior nerve root
involvement– Paralysis
• Seizures• H/A• Hemiparesis
Neurosyphilis
Treatment• Antibiotics• Both partners• Infants
Varicella / Herpes Zoster
Pathophysiology• Virus• Mode of transmission
– Airborne– Contact
• Incubation period – 2 weeks
Varicella / Herpes Zoster
Pathophysiology• Exposure • Prodromal stage
– General malaise– No rash– Contagious!
Varicella / Herpes Zoster
• Rash stage– CHICKEN POX’s– Vesicular & pustular– Spread rapidly– New lesions for 2-3 days
Varicella / Herpes Zoster
• Scab stage– Lesion begin to dry– No new lesion– lesions crusted
• Not contagious
Varicella / Herpes Zoster
• Dormant stage– Virus retreats– Dormant– Dorsal horn of the spinal
cord
Varicella / Herpes Zoster
• Reactivated– Later!!!!
• Stress• Decreased immune
system
– Reactivated– Along peripheral nerve– Shingles
Varicella / Herpes Zoster
S&S of shingles• Tingling• Itching• Pain• Rash
– Red bumps– Blisters
Varicella / Herpes Zoster
• Prevention– Varicella vaccine– (85% effective)
• Treatment– Self-limiting– Anti-viral meds– NO aspirin
• Reye syndrome• Liver failure
Question
• An adult who has never had chicken pox’s or the varicella vaccine and is exposed to a child with chicken pox, is at risk of developing what?
A. Chicken pox’sB. ShinglesC. Nothing, varicella only affects children
Question
• An adult who has never had chicken pox’s or the varicella vaccine is exposed to an adult with shingles. What is the adult at risk of developing?
A. Chicken pox’sB. ShinglesC. Syphilis
Question
• An adult who had chicken pox’s as a child is exposed to an adult with shingles. What is the adult at risk of developing?
A. Chicken pox’sB. ShinglesC. Nothing
Question
• What must happen before a person can develop shingles?
A. They must be a door mat B. They must go to sleep C. They must have cancerD. They must have chicken pox’sE. They must have spinal cord injury
Question
• Which of the following can lead to an outbreak in shingles (of a patient with dormant herpes Zoster)
A. StressB. CancerC. Immunosuppressant medicationD. Exposure to a person with chicken pox’sE. Exposure to a person with shingles
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