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Rehab Quiz One Review!
Spinal cord injury & complete transsection of cord
Complete spinal cord transection
1. Quadriplegia with injuries of the cervical spinal cord
2. Paraplegia with injuries of the thoracic spinal cord
Muscle flaccidity
Loss of all reflexes below the level of injury
Loss of pain, temperature, touch, pressure, and proprioception below the level of injury
Pain at the site of injury caused by a zone of hyperesthesia above the injury
Atonic bladder and bowel
Paralytic ileus with distention
Loss of vasomotor tone in the lower body parts; low and unstable blood pressure
Loss of perspiration below the level of injury
Loss or extreme depression of genital reflexes such as penile erection and
bulbocavernous reflex
Dry and pale skin; possible ulceration over bony prominences
Respiratory impairment
Complete: All tracts in the spinal cord completely disrupted; all cord-mediated functions
below the transection are completely and permanently lost
Know autonomic disreflexia
Observe the patient with an upper SCI (above the level of T6) for signs of autonomic dysreflexia
(hyperreflexia). Although it does not occur frequently, autonomic dysreflexia is an excessive,
uncontrolled sympathetic output. It is characterized by severe hypertension, bradycardia, severe
headache, nasal stuffiness, and flushing (Chart 45-10). The cause of this syndrome is a noxious
stimulus—usually a distended bladder or constipation. This is a neurologic emergency and must
be promptly treated to prevent a hypertensive stroke! Chart 45-11 lists emergency care for
autonomic dysreflexia.
Cervical spinal cord injury (nursing mgmt, priorities)… several questions here
ABCs. Keep the distracters in mind
Assessing the ABCs (airway, breathing, circulation) is the priority for any trauma patient.
Therefore the first priority for the patient with an SCI is to assess the patient's airway,
breathing pattern, and circulation status. The airway may be compromised because of
foreign body obstruction from the tongue or teeth due to facial trauma, injury to the
larynx, or mandibular (jaw) fracture (Harris & Sethi, 2006). After an airway is
established, assess the patient's breathing pattern. The patient with a cervical SCI is at
high risk for respiratory compromise because the cervical spinal nerves (C3-5) innervate
the phrenic nerve, which controls the diaphragm. A significant head injury,
pneumothorax (air in the chest cavity), hemothorax (blood in the chest cavity), and/or
fractured ribs may also cause respiratory distress. Injuries to the occiput (back of the
head) and C2 are more likely to occur in the older adult who fell from a low height.
Endotracheal intubation with mechanical ventilation may be necessary to prevent
respiratory arrest.
Assess for indications of intra-abdominal hemorrhage or hemorrhage or bleeding around
fracture sites. Indicators of hemorrhage include hypotension and tachycardia with a weak
and thready pulse.
Use the Glasgow Coma Scale (see Chapter 43) or other agency-approved assessment tool
to assess the patient's level of consciousness (LOC). Cognitive impairment as a result of
an associated traumatic brain injury (TBI) or substance abuse is common in patients with
traumatic SCIs. Perform a detailed assessment of the patient's motor and sensory status to
assist in determining the level of injury and serve as baseline data for future comparison.
The level of injury is the lowest neurologic segment with intact or normal motor and
sensory function. Tetraplegia (also called quadriplegia) (paralysis) and quadriparesis
(weakness) involve all four extremities, as seen with cervical cord and upper thoracic
injury. Paraplegia (paralysis) and paraparesis (weakness) involve only the lower
extremities, as seen in lower thoracic and lumbosacral injuries or lesions.
Spinal shock, also called spinal shock syndrome, occurs immediately as a concussion
response to the injury. The patient has flaccid paralysis and loss of reflex activity below
the level of the lesion. It often lasts less than 48 hours but may continue for several weeks
(McCance & Huether, 2006). Muscle spasticity begins in patients with cervical or high
thoracic injuries when spinal shock is resolved.
Assessment of Sensory and Motor Ability. Sensation is carried from the peripheral nerves to the spinal cord and up to the cerebral
cortex through several specific tracts. Injury to the spinal cord may prevent those
impulses from reaching the brain. To test sensory abilities, ask the patient to close his or
her eyes. Touch the skin with a clean safety pin or cotton-tipped applicator, and ask
whether he or she can feel the pinprick or light touch. Compare bilateral responses.
Follow the sensory distribution of the skin dermatomes (see Fig. 43-5 in Chapter 43),
with the examination beginning in the area of reported loss of sensation and ending where
sensation becomes normal. For example, sensation of the top of the foot and calf of the
leg is spinal skin segment (dermatome) levels L3, L4, and L5. The area at the level of the
umbilicus is T10, the clavicle (collarbone) is C3 or C4, and finger sensation is C7 and
C8. The patient may report a complete sensory loss, hypoesthesia (decreased sensation),
or hyperesthesia (increased sensation).
The patient's proprioceptive (position sense) function may be assessed. Request that the
patient again close his or her eyes. Next move one of his or her fingers or toes up or
down. Ask the patient to identify the position of the digits.
In addition to performing a routine motor evaluation of the patient, selected muscles are
tested in a more systematic fashion (Chart 45-8). Many scales are available to measure
motor function. The American Spinal Injury Association (ASIA) recommends a five-
point grading scale, with 0 being no movement and 5 being normal strength (see Table
52-2 in Chapter 52). Ask the patient to flex and extend the elbows, elevate both arms off
the bed, flex and extend the wrists and fingers, and touch each finger to the thumb.
Patients with spinal injuries at the fifth or sixth cervical vertebra often can flex but not
extend their arms. Observe the patient's ability to move the lower extremities. Ask him or
her to wiggle the toes, flex and extend the feet and knees, and move one or both hips.
The advanced practice nurse or health care provider may also test deep tendon reflexes
(DTRs), including the biceps (C5), triceps (C7), patella (L3), and ankle (S1). It is not
unusual for these reflexes, as well as all movement or sensation, to be absent immediately
after the injury because of spinal shock. After shock has resolved, the reflexes may return
if the lesion is incomplete or involves upper motor neurons.
BEST PRACTICE FOR PATIENT SAFETY & QUALITY CARE
Assessing Motor Function in the Patient with a Spinal Cord
Injury • To assess C4-5, apply downward pressure while the patient shrugs his or her
shoulders upward.
• To assess C5-6, apply resistance while the patient pulls up his or her arms.
• To assess C7, apply resistance while the patient straightens his or her flexed arms.
• To assess C8, make sure the patient is able to grasp an object and form a fist.
• To assess L2-4, apply resistance while the patient lifts his or her legs from the
bed.
• To assess L5, apply resistance while the patient dorsiflexes his or her feet.
• To assess S1, apply resistance while the patient plantar flexes his or her feet.
Cardiovascular and Respiratory Assessment. Cardiovascular dysfunction results from disruption of sympathetic fibers of the
autonomic nervous system (ANS), especially if the injury is above the sixth thoracic
vertebra. Bradycardia, hypotension, and hypothermia occur because of loss of
sympathetic input. These changes may lead to cardiac dysrhythmias. A systolic blood
pressure below 90 mm Hg requires treatment because lack of perfusion to the spinal cord
could worsen the patient's condition. In addition, the lack of sympathetic or hypothalamic
control causes the patient to lose thermoregulatory functions. As a result, the body tends
to assume the temperature of the environment and attempts to compensate by increasing
extracellular fluid.
A patient with a cervical SCI is at risk for respiratory problems resulting from
immobility or from an interruption of spinal innervation to the respiratory muscles. In
collaboration with the respiratory therapist (RT), if available, perform a complete
respiratory assessment, including pulse oximetry for arterial oxygen saturation. The RT
should also evaluate vital capacity and minute volume as part of the assessment. These
tests are repeated as the patient's clinical status requires.
(Ignatavicius, Donna D.. Medical-Surgical Nursing: Patient-Centered Collaborative
Care, Single Volume, 6th Edition. W.B. Saunders Company, 022009. 48.5.1.5.1.2.1).
<vbk:9781416037620#outline(48.5.1.5.1.2.1)>
Seizure patients. What do you do & not do
Precautions are taken to prevent the patient from injury if a seizure occurs. Specific
seizure precautions vary depending on health care agency policy. Be sure that oxygen
and suctioning equipment with an airway are readily available. If the patient does not
have an IV access, insert a saline lock, especially for those patients who are at significant
risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV
drug therapy must be given to stop the seizure.
Siderails should be in the “up” position at all times. Siderails are rarely the source of
significant injury, and the effectiveness of the use of padded siderails to maintain safety
is debatable. Padded siderails may embarrass the patient and the family. Follow agency
policy about the use of siderails because they are now classified as a restraint device.
Other methods to protect the patient, such as placing a mattress on the floor, may be used
instead of siderails.
Padded tongue blades do not belong at the bedside and should NEVER be inserted into
the patient's mouth because the jaw may clench down as soon as the seizure begins!
Forcing a tongue blade or airway into the mouth is more likely to chip the teeth and
increase the risk of aspirating tooth fragments than prevent the patient from biting the
tongue. Furthermore, improper placement of a padded tongue blade can obstruct the
airway.
One med question… she is hoping to delete… one on heparin she wants to
delete.
Couple drug calc questions….. simple
Risk factors assoc with seizures
The actions taken during a seizure should be appropriate for the type of seizure (Chart 44-5). For
example, for a simple partial seizure, observe the patient and document the time that the seizure
lasted. Redirect the patient's attention away from an activity that could cause injury. Turn the
patient on the side during a generalized tonic-clonic or complex partial seizure because he or she
may lose consciousness. If possible, turn the patient's head to the side to prevent aspiration and
allow secretions to drain. Remove any objects that might injure the patient.
BEST PRACTICE FOR PATIENT SAFETY & QUALITY CARE
Care of the Patient During a Tonic-Clonic or Complete Partial Seizure
• Protect the patient from injury.
• Do not force anything into the patient's mouth.
• Turn the patient to the side to keep the airway clear.
• Loosen any restrictive clothing the patient is wearing.
• Maintain the patient's airway and suction as needed.
• Do not restrain or try to stop the patient's movement; guide movements if necessary.
• Record the time the seizure began and ended.
• At the completion of the seizure:
• Take the patient's vital signs.
• Perform neurologic checks.
• Keep the patient on his or her side.
• Allow the patient to rest.
• Document the seizure (see Chart 44-6).
It is not unusual for the patient to become cyanotic during a generalized tonic-clonic seizure. The
cyanosis is generally self-limiting, and no treatment is needed. Some health care providers prefer
to give the high-risk patient (e.g., older adult, critically ill or debilitated patient) oxygen by nasal
cannula or facemask during the postictal phase. He or she is not restrained because this may
cause injury and may worsen the situation, causing more seizure activity. For any type of
seizure, carefully observe the seizure and document assessment findings (Chart 44-6).
Emergency Care:
Acute Seizure and Status Epilepticus Management. Seizures occurring in greater intensity,
number, or length than the patient's usual seizures are considered acute. They may also appear in
clusters that are different from the patient's typical seizure pattern. Treatment with lorazepam
(Ativan, Apo-Lorazepam ) or diazepam (Valium, Meval , Vivol, Diastat [rectal
diazepam gel]) may be given to stop the clusters to prevent the development of status epilepticus.
IV phenytoin (Dilantin) or fosphenytoin (Cerebyx) may be added.
Status epilepticus is a medical emergency and is a prolonged seizure lasting longer than 5
minutes or repeated seizures over the course of 30 minutes. It is a potential complication of all
types of seizures. Seizures lasting longer than 10 minutes can cause death! Common causes of
status epilepticus include:
• Sudden withdrawal from antiepileptic drugs
• Infections
• Acute alcohol or drug withdrawal
• Head trauma
• Cerebral edema
• Metabolic disturbances
Convulsive status epilepticus must be treated promptly and aggressively! Establish an airway
and notify the health care provider immediately if this problem occurs! Establishing an airway is
the priority for this patient's care. Intubation by an anesthesia provider or respiratory therapist
(RT) may be necessary. Administer oxygen as indicated by the patient's condition. If not already
in place, establish IV access with a large-bore catheter, and start 0.9% sodium chloride. The
patient is usually placed in the intensive care unit for continuous monitoring and management.
Ross stages of grief
Denial — "I feel fine."; "This can't be happening, not to me."
Denial is usually only a temporary defense for the individual. This feeling is generally
replaced with heightened awareness of situations and individuals that will be left behind
after death.[1]
Anger — "Why me? It's not fair!"; "How can this happen to me?"; "Who is to blame?"
Once in the second stage, the individual recognizes that denial cannot continue. Because
of anger, the person is very difficult to care for due to misplaced feelings of rage and
envy. Any individual that symbolizes life or energy is subject to projected resentment and
jealousy.[1]
Bargaining — "Just let me live to see my children graduate."; "I'll do anything for a few
more years."; "I will give my life savings if..."
The third stage involves the hope that the individual can somehow postpone or delay
death. Usually, the negotiation for an extended life is made with a higher power in
exchange for a reformed lifestyle. Psychologically, the person is saying, "I understand I
will die, but if I could just have more time..."[1]
Depression — "I'm so sad, why bother with anything?"; "I'm going to die . . . What's the
point?"; "I miss my loved one, why go on?"
During the fourth stage, the dying person begins to understand the certainty of death.
Because of this, the individual may become silent, refuse visitors and spend much of the
time crying and grieving. This process allows the dying person to disconnect oneself
from things of love and affection. It is not recommended to attempt to cheer up an
individual who is in this stage. It is an important time for grieving that must be
processed.[1]
Acceptance — "It's going to be okay."; "I can't fight it, I may as well prepare for it."
This final stage comes with peace and understanding of the death that is approaching.
Generally, the person in the fifth stage will want to be left alone. Additionally, feelings
and physical pain may be non-existent. This stage has also been described as the end of
the dying struggle.[1]
Types of seizures & symptoms assoc w/ each: generalized, partial & absence
The International Classification of Epileptic Seizures recognizes three broad categories of
seizure disorders: generalized seizures, partial seizures, and unclassified seizures.
Generalized Seizures Six types of generalized seizures may occur and involve both cerebral hemispheres. The
tonic-clonic seizure lasting 2 to 5 minutes begins with a tonic phase that causes
stiffening or rigidity of the muscles, particularly of the arms and legs, and immediate loss
of consciousness. Clonic or rhythmic jerking of all extremities follows. The patient may
bite his or her tongue and may become incontinent of urine or feces. Fatigue, acute
confusion, and lethargy may last up to an hour after the seizure.
Occasionally, only tonic or clonic movement may occur. A tonic seizure is an abrupt
increase in muscle tone, loss of consciousness, and autonomic changes lasting from 30
seconds to several minutes. The clonic seizure lasts several minutes and causes muscle
contraction and relaxation.
The absence seizure is more common in children and tends to run in families. It consists
of brief (often just seconds) periods of loss of consciousness and blank staring as though
the person is daydreaming. The patient's eyes may flutter and automatisms (involuntary
behaviors) such as lip smacking and picking at clothes may also occur. He or she is not
aware of these behaviors. The patient returns to baseline immediately after the seizure.
Left undiagnosed or untreated, the seizures may occur frequently throughout the day,
interfering with school or other daily activity.
The myoclonic seizure causes a brief jerking or stiffening of the extremities that may
occur singly or in groups. Lasting for just a few seconds, the contractions may be
symmetric (both sides) or asymmetric (one side).
In an atonic (akinetic) seizure, the patient has a sudden loss of muscle tone, lasting for
seconds, followed by postictal (after the seizure) confusion. In most cases, these seizures
cause the patient to fall, which may result in injury. This type of seizure tends to be most
resistant to drug therapy.
Partial Seizures Partial seizures, also called focal or local seizures, begin in a part of one cerebral
hemisphere. They are further subdivided into two main classes: complex partial seizures
and simple partial seizures. In addition, some partial seizures can become generalized
tonic-clonic, tonic, or clonic seizures. Partial seizures are most often seen in adults and
generally are less responsive to medical treatment when compared with other types.
Complex partial seizures may cause loss of consciousness (syncope), or “black out,” for
1 to 3 minutes. Characteristic automatisms may occur as in absence seizures. The patient
is unaware of the environment and may wander at the start of the seizure. In the period
after the seizure, he or she may have amnesia (loss of memory). Because the area of the
brain most often involved in this type of epilepsy is the temporal lobe, complex partial
seizures are often called psychomotor seizures or temporal lobe seizures.
The patient with a simple partial seizure remains conscious throughout the episode.
He or she often reports an aura (unusual sensation) before the seizure takes place. This
may consist of a “déjà vu” (already seen) phenomenon, perception of an offensive
smell, or sudden onset of pain. During the seizure, the patient may have one-sided
movement of an extremity, experience unusual sensations, or have autonomic
symptoms. Autonomic changes include a change in heart rate, skin flushing, and
epigastric discomfort.
Unclassified, or idiopathic, seizures account for about half of all seizure activity. They
occur for no known reason and do not fit into the generalized or partial classifications.
Priorities in cervical spine injuries
The highest priority intervention is to establish a patent airway. Even minutes without an
adequate oxygen supply in humans can lead to cerebral injury that can progress to anoxic
brain death. The airway is cleared of any secretions or debris either with a suction
catheter or manually if necessary. The cervical spine is protected in any trauma patient
with the potential for spinal injury by manually aligning the neck in a neutral, in-line
position and using a jaw-thrust maneuver when establishing an airway. Supplemental
oxygen is required for all patients who require resuscitation. In general, a non-rebreather
mask is best for the spontaneously breathing patient. Bag-valve-mask (BVM) ventilation
with the appropriate airway adjunct and a 100% oxygen source is indicated for the person
who needs ventilatory assistance during resuscitation. A patient with significantly
impaired consciousness requires a definitive airway such as an endotracheal tube
(American College of Surgeons, 2004) (Fig. 10-3). After endotracheal intubation, a
mechanical ventilator is employed. Initially, oxygen in high concentration (FIO2 100%) is
administered; lower concentrations may be requested after the patient's condition has
improved.
After the airway is successfully secured, breathing becomes the next priority in the
primary survey. This assessment determines whether or not ventilatory efforts are
effective—not only whether or not the patient is breathing. The focus is on auscultation of
breath sounds and evaluation of chest expansion, respiratory effort, and any evidence of
chest wall trauma or physical abnormalities. Both apneic patients and those with poor
ventilatory effort need BVM ventilation for support until endotracheal intubation is
performed and a mechanical ventilator is used. If cardiopulmonary resuscitation (CPR)
becomes necessary, the mechanical ventilator must be disconnected and the patient
manually ventilated with a BVM device. Lung compliance can be assessed through
sensing the degree of difficulty in ventilating the patient with the BVM.
Another lifesaving intervention that may be performed in this phase is chest
decompression, either with a needle or chest tube to vent trapped air. The main indication
for chest decompression is clinical evidence of a tension pneumothorax, which can pose a
critical threat to both breathing and circulation. Symptoms include decreased to absent
breath sounds over the affected side, respiratory distress, hypotension, jugular vein
distention, and tracheal deviation (late). If unrelieved, a tension pneumothorax causes
mediastinal shift, cardiovascular collapse, and death. Causes of tension pneumothorax
include barotrauma from BVM ventilation or other positive-pressure ventilation, blunt or
penetrating chest trauma, and expansion of a simple pneumothorax.
When effective ventilation is ensured, the priority shifts to circulation. The adequacy of
heart rate, blood pressure, and overall perfusion becomes the focus of the assessment.
Common threats to circulation include cardiac arrest, myocardial dysfunction, and
hemorrhage leading to a shock state. Interventions are targeted at restoring effective
circulation through cardiopulmonary resuscitation, hemorrhage control, IV vascular
access with fluid and blood administration as necessary, and drug therapy. External
hemorrhage is usually quite obvious and best controlled with firm, direct pressure on the
bleeding site with thick, dry dressing material (Laskowski-Jones, 2006c). This method is
effective in decreasing blood flow for the majority of wounds—even those caused by
amputations (Laskowski-Jones, 2006b). Thus tourniquets that occlude arterial blood flow
distal to the injury should not be used to control bleeding unless hemorrhage is so severe
that the risk to limb viability is justified to save a life. Internal hemorrhage is a more
hidden complication that must be suspected in injured patients or those who present in a
shock state.
Bells palsy vs. trigeminal neuralgia (know difference)
Bell’s palsy is a unilateral paralysis of the facial nerve, thought to result from trauma to the
nerve, compression of the nerve, or infection, of which herpes simplex virus is thought to be
the most common. Any or all branches of the nerve may be affected. The person may not be
able to close an eye or control salivation on the affected side. It usually resolves over weeks
but can leave some permanent damage, including decreased taste and hypersensitivity to
noise on the affected side. (CN 7)
Trigeminal neuralgia is a neurologic condition of the trigeminal facial nerve (CN 5),
characterized by paroxysms of flashing, stablike pain radiating along the course of a branch
of the nerve from the angle of the jaw. It is caused by degeneration of the nerve or by
pressure on it. Any or all of the three branches of the nerve may be affected. Neuralgia of the
first branch results in pain around the eyes and over the forehead; of the second branch, in
pain in the upper lip, nose, and cheek; of the third branch, in pain on the side of the tongue
and the lower lip. The momentary bursts of pain recur in clusters lasting many seconds.
Paroxysmal episodes of the pains may last for hours.
Chronic illness & disease: changes to increase our life expectancy… impacts.
Major s/s of myasthenia gravis
an abnormal condition characterized by chronic fatigability and muscle weakness,
especially in the face and throat, as a result of a defect in the conduction of nerve
impulses at the neuromuscular junction.
observations
Muscular fatigability in myasthenia gravis is caused by the inability of receptors at the
myoneural junction to depolarize because of a deficiency of acetylcholine; hence the
diagnosis may be made by administering an anticholinesterase drug and observing
improved muscle strength and stamina. The onset of symptoms is usually gradual, with
ptosis of the upper eyelids, diplopia, and weakness of the facial muscles. The weakness
may then extend to other muscles innervated by the cranial nerves, particularly the
respiratory muscles. Muscular exertion aggravates the symptoms, which typically vary
over the course of the day. The disease occurs in younger women more often than in
older women and in men over 60 years of age more often than in younger men.
interventions
Anticholinesterase drugs are given. The edrophonium test is used to determine the
optimal maintenance dose. Neostigmine or pyridostigmine is the drug most often used.
nursing considerations
Physical activity is restricted and bed rest encouraged. Anticholinesterase drugs are
usually administered before meals, and the patient is monitored for toxic side effects.
Myasthenic crisis may require emergency respiratory assistance. The patient's diet may
have to be adjusted if the ability to chew and swallow is affected.
(Mosby. Mosby's Dictionary of Medicine, Nursing & Health Professions, 8th Edition.
Mosby, 122008.).
<vbk:978-0-323-04937-5>
What is rehab nursing all about
Difference between primary & secondary prevention (cancer)
Cultural competence: how do we get health care providers culturally
competent.
s/s of diff headaches (migraines, cluster, etc.
Cluster headaches: a condition characterized by attacks of intense unilateral pain, occurring
most often over the eye and forehead. It is accompanied by flushing and watering of the eyes and
nose. Cluster headaches are more common in males and are associated with alcohol use. The
attacks occur in groups with a duration of several hours.
Migraines: a recurring headache characterized by unilateral onset, severe throbbing pain,
photophobia, phonophobia, and autonomic disturbances during the acute phase, which may last
for hours or days. The disorder occurs more frequently in women than in men, and a
predisposition to migraine may be inherited. The exact mechanism responsible for the disorder is
not known, but the head pain may be related to dilation of extracranial blood vessels, which may
be the result of chemical changes that cause spasms of intracranial vessels. Allergic reactions,
excess carbohydrates, iodine-rich foods, alcohol, bright lights, or loud noises may trigger attacks,
which often occur during a period of relaxation after physical or psychic stress.
observations
An impending attack may be heralded by visual disturbances, such as aura, flashing lights
or wavy lines, or by a strange taste or odor, numbness, tingling, vertigo, tinnitus, or a
feeling that part of the body is distorted in size or shape. The acute phase may be
accompanied by nausea, vomiting, chills, polyuria, sweating, facial edema, irritability, and
extreme fatigue. After an attack the individual often has dull head and neck pains and a
great need for sleep.
interventions
Ergotamine tartrate preparations that constrict cranial arteries can usually prevent the
headache from developing if administered early in the onset via injection, suppository,
tablet, or nasal spray. Ergotamine tartrate is also available in combination with other drugs,
such as caffeine, phenobarbital, and belladonna. Migraine patients unable to tolerate ergot
preparations may use other analgesics, including acetaminophen, NSAIDs, triptan, and
propoxyphene. If headaches happen frequently, a prophylactic medication may be taken
daily.
Tension headache: a pain that affects the head as the result of overwork or emotional strain and
that involves tension in the muscles of the neck, face, and shoulder.
focus a little extra on migraines
parkinsons disease (diagnostically, what does it look like, etiology)
a slowly progressive degenerative neurologic disorder characterized by resting tremor,
pill rolling of the fingers, a masklike facies, shuffling gait, forward flexion of the trunk,
loss of postural reflexes, and muscle rigidity and weakness. It is usually an idiopathic
disease of people over 60 years of age; it may occur in younger people, however,
especially after acute encephalitis or carbon monoxide or metallic poisoning, particularly
by reserpine or phenothiazine drugs. Typical pathologic changes are destruction of
neurons in basal ganglia; loss of pigmented cells in the substantia nigra; and depletion of
dopamine in the caudate nucleus, putamen, and pallidum, structures in the neostriatum
that normally contain high levels of the neurotransmitter dopamine. Signs and symptoms
of Parkinson's disease, which include resting tremor, bradykinesias, drooling, increased
appetite, intolerance to heat, oily skin, emotional instability, and defective judgment, are
increased by fatigue, excitement, and frustration. Palliative and symptomatic treatment of
the disease focuses on correcting the imbalance between depleted dopamine and
abundant acetylcholine in the striatum because dopamine normally appears to inhibit
excitatory cholinergic activity in this brain area. Levodopa, a dopamine precursor that
crosses the blood-brain barrier, may be used, but many patients experience side effects,
such as nausea, vomiting, insomnia, orthostatic hypotension, and mental confusion.
Carbidopa-levodopa, which contains an inhibitor of the enzyme dopa decarboxylase,
limits peripheral metabolism of levodopa and thus causes fewer side effects.
Anticholinergic drugs, such as benztropine mesylate, biperiden, procyclidine, and
trihexyphenidyl, may be used as therapeutic agents but often cause ataxia, blurred vision,
constipation, dryness of the mouth, mental disturbances, slurred speech, and urinary
urgency or retention. Amantadine hydrochloride, an antiviral drug with antiparkinsonian
activity, promotes the accumulation of dopamine in extracellular or synaptic sites, but the
therapeutic effectiveness may not last more than 3 months in some patients; side effects,
such as mental confusion, visual disturbances, and seizures, occur infrequently.
drug for parkinsons (primary one)
know trigeminal neuralga vs. bells palsy
guillan barre… most common type…
an idiopathic, peripheral polyneuritis that may occur 1 to 3 weeks after a mild episode of fever
associated with a viral infection or with immunization but that can also occur with no preceding
illness. Symmetric pain and weakness affect the extremities, and paralysis may develop. The
neuritis may spread to the trunk and face. Symptoms vary in intensity from mild to severe
enough to require critical nursing care, including ventilator assistance. Treatment consists of
supportive care and high IV doses of immunoglobulins. Recovery depends on the extent of
neuritis and may take weeks to many months. observations
Manifestations may range from mild to severe and generally develop 1 to 3 weeks after an upper
respiratory or gastrointestinal infection. The first sign is symmetric muscle weakness in the distal
extremities accompanied by paresthesia. This weakness spreads upward to the arms and trunk
and then to the face. This ascension usually peaks about 2 weeks after onset. Deep tendon
reflexes are commonly absent. Difficulty chewing, swallowing, and speaking may occur, and
respiratory paralysis may develop. Signs of autonomic nervous system dysfunction, such as
facial flushing, profuse diaphoresis, bowel and bladder atony, postural hypotension,
hypertension, tachycardia, and heart block, may develop. Deep, aching muscle pain is also
common. The diagnosis is based on history and clinical presentation. Lumbar puncture results
typically reveal an increase in cerebrospinal fluid protein without an increase in lymphocyte
count. Electromyography is markedly abnormal with reduced nerve conduction velocity. About
5% of those affected die of respiratory failure. Another 10% have permanent residual neurologic
deficits. About 90% of all survivors make a full recovery, but the recovery time may be as long
as 3 years.
interventions
Treatment is supportive, with the use of IV immunoglobulins or plasmapheresis to counteract
neurologic defect and speed recovery of neurologic deficit. Subcutaneous heparin is given to
prevent thromboembolism. Tracheostomy and mechanical ventilation are necessary to treat
respiratory paralysis, and breathing function tests should be performed and followed closely.
Continuous cardiac monitoring is done to detect possible sinus tachycardia and/or
bradyarrhythmias.
nursing considerations
Care for patients with Guillain-Barré disease is complex and multifaceted. In acute disease,
nursing focus is on careful assessment of ascending paralysis and monitoring of respiratory
function to ensure airway patency and adequate gas exchange. Continuing assessments are
needed of corneal, gag, and swallow reflexes. Blood pressure is monitored for fluctuations;
cardiac rate and rhythm are monitored for tachycardia, bradycardia, heart block, and asystole.
Pain assessment and management are required for paresthesias, hyperesthesias, muscle cramps,
and deep muscle aches. Complications related to autonomic dysfunction, paralysis, and
immobility (e.g., pressure sores, thromboemboli, aspiration, urinary retention, fecal impaction,
and nerve palsies) must be prevented. This includes a rigorous turning and positioning schedule,
regular passive range-of-motion exercises, careful pulmonary toilet and feeding routines,
application of thromboembolic stockings, and institution of bowel and bladder programs.
Communication systems may be needed if the individual is on a ventilator or has facial paralysis.
Emotional and social support are needed to reduce fear and anxiety. Rehabilitation may be
indicated for recovery of functional abilities and long-term adaptation to permanent neurologic
deficit.
cervical spinal cord injury question
nursing goals for end of life care: palliative
cultural competence for persons of Chinese descent
Restless leg syndrome (patient teaching):
any condition that interferes with normal sleep patterns, such as sleep apnea, phase shift, use
of alcohol and certain drugs, excessive sleepiness, sleep walking, nightmares, sleep paralysis,
restless leg syndrome, and narcolepsy. Treatment may include medications, relaxation,
avoidance of stimulants, and referral to sleep disorder clinics.
Pt teaching in regard to risk for falls
Know what status epilepticus is
a medical emergency characterized by continuous seizures lasting more than 30 minutes
without interruption. Status epilepticus can be precipitated by the sudden withdrawal of
anticonvulsant drugs, inadequate body levels of glucose, a brain tumor, a head injury, a high
fever, or poisoning. Therapy includes IV administration of anticonvulsant drugs, nutrients,
and electrolytes. An adequate airway is usually maintained with a nasopharyngeal or
endotracheal tube.
Challenges of a caregiver taking care of a disabled person