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AH II
Altered perception
| Question | Answer |
|---|---|
| Alzheimers | loss of memory; reasoning; judgement; and language to such an extent that it interferes with everyday life |
| most common form of dimentia in 65+ | alzheimers |
| etiology of alzheimers | no identifiable direct cause; increased age; chromosamal link |
| patho of alzheimers | disruption of neuron communication, metabolism & repair; Beta-amyloid plaques; neurofibrillary tangles; decreased acetylcholine |
| preclinical alzheimers | before symptoms appear the area around the hippocampus begins to shrink, then in 10-20 yrs memory loss occurs |
| mild alzheimers STAGE 1 | memory disturbance noted by family; get lost easily; poor judgement; loss of interest in previously important stuff; careless at work or home; difficulty problem solving; trouble adapting to new surroundings |
| moderate alzheimers STAGE 2 | pacing; wandering (night is dangerous); language disturbance; spontaneous language difficult; papilalia; echolalia; apraxia; hyperorality; irritability; occasional incontinence |
| nursing considerations for disturbed thought process | enhance memory (calander, clock) allow to reminisce ( long term memory intact longer, reorienting = frustration); repetition is helpful for information retention |
| alzheimer risk for injury in home | disconnect electrical appliances; watch loose rugs; adequate lighting; turn down hot water; lock doors in different manner than normal (near top out of sight) |
| alzheimer risk for injury in hospital | monitor closely; family at bedside helps to orient them |
| lewy body dementia | brain cell by products that build up throughout the brain; progress rapidly |
| sx of lewy body dementia | range from parkinson like to alzheimers; bradykinesia; rigidity; tremor; shuffling gate; visual hallucinations (may be first sx) |
| nursing care for alzheimers | good history & assessment; concentrate on ADLs; family & coworker comments; reaction to change of environment; personality change; head injury; social isolation; paranoid; abusive language |
| verbal communication in alzheimers | use a slow calming voice; watch their non verbals (pacing, waving arms, hostility) decrease stimuli; approach calmly; genly distract; bodylanguage & words should match, use one form of communication at a time (visual/auditory) |
| urge incontinence | toiled before need q 3 hrs; watch for nonverbal ques; restrict fluids after supper |
| bowel incontinence | create a pattern from usual routine; bed pad/brief; avoid foley cath |
| alzheimer self care | protect autonomy in early stages (little reminders); step by step directions; allow enough time; constant encouragement |
| caregiver strain | they grieve the person they used to know; each decline is another grief; watch for demanding behavior/incontinence; offer suggestions for respite; issues of feeding tube & DNR |
| headache assessment | location; character of pain; duration; frequency; methods used to tx; localized tenderness to touch; precipitating factors; familial tendencies |
| tension headache | from muscle contraction pain builds slowly; lasts for days; vice like pain in head & neck |
| cluster headaches | short attacks of periorbital pain more spring/fall; last 15min - 3 hrs; 1-4 x per day; deep boring pain; usually unilateral |
| trigger for cluster headache | alcohol consumption |
| tx of cluster headache | lithium; steroid dose pack; O2 at 9L per mask for 15 min |
| migraine headache (vascular) | vasospasm or ischemia of intracranial vessels; begin in puberty; more common in women; associated w/ hormone change |
| sx of migraine | last 4 - 72 hrs; unilateral; pulsating; throbbing; photophobia;phonophobia; N&V; focal neuro sx; visual aura pre headache |
| migraine triggers | stress; missing meals; tyramine rich food (pickles, aged cheese, red wine,); nitrates(cured meat); alcohol |
| tx of migraines | quiet;dark environ; ibuprofen;caffine;ergotamine; sumatriptan (imatrex); decrease daily stress & fatigue |
| preventative meds for migraine | amytriptyline; valporate; verapamil |
| migraine drug of choice | ergotamine |
| ergotamine | unknown method; vasoconstriction; anti inflamm; seritonin blocking; can cause N&V give w/ antiemetic; take w/ triptans due to prolonged vasospasms; metabolized in liver & kidney |
| triptans - sumatriptan (imitrex) | for migraines; vasoconstriction; inhibits release of compund that causes infamm; decreases inflamm around blood vessels |
| side effects of triptans | coronary vasospasm; transient chest heaviness; not given to pt w/ CAD |
| increased intercranial pressure (ICP) | skull is closed vault; balance between brain tissue, blood, cerebrospinal fluid; when there is an increase in one ther has to be a decrease in one of the others; compensation or compliance |
| patho of ICP | caused by traction on cerebral blood vessels from swelling tissue; pressure on pain sensitive dura; depends on location of pressure- tumor; hemorrhage |
| sx of ICP | usually subtle; change in LOC; decreased glasgow coma scale;change in speech; pupil change;motor/sensory change; change in HR or rhythm; headache N&V blurred vision |
| respiratory patterns w/ ICP | cheyne-strokes; central neurogenic hypervent; apneustic breathing; cluster breathing; ataxic breathing |
| cheyne-strokes | regular respirations w/ regular periods of apnea |
| central neurogenic hyperventilation | regular deep respirations |
| apneustic breathing | regular but deep inspiration and expiration w/ regular periods of apnea |
| cluster breathing | clusters of irregular inspiration and experation between periods of apnea |
| ataxic breathing | completely irregular respirations with apneic periods |
| diagnosing increased ICP | symptoms; skull x-ray to see shifts; CT/MRI to see fluid, tumor, abcess; lumbar puncture to risky of herniation of brain stem |
| tx of increased ICP | maintain cerebral O2; decrease ICP; maintain cerebral perfusion high dose barbiturates; neuromuscluar blocking agents |
| how to maintain cerebral O2 w/ ICP | intubation/ventilation; O2 @ 90-100%; steroid to reduce edema |
| how to decrease ICP | hyperventilation to remove more CO2; osmotic diuretic;keep HOB elevated; neck in neutral position to facilitate venous drainage |
| how to maintain cerebral perfusion w/ ICP | IV fluid =prevent hypotension & secondary brain injury; vasoactive med to incr./dec. BP; ICP monitoring in ventricles; control body temp, prevent chills; prevent seizure; sedation; mannitol (hyperosmotic) |
| purpose of barbiturates w/ ICP | decrease metabolic needs of brain; provides pain control & sedation; requires mech. ventilation |
| purpose of neuromuscular blocking agents w/ ICP | skeletal muscle relaxation; pain med & sedatives are needed too |
| Increased ICP posturing | decorticate; decerebrate, bilateral faccidity |
| decorticate | abnormal fexion due to brain damage at the cortical level |
| decerebrate | abnormal extension; usualy a more serious injury & worse prognosis |
| bilateral flaccidity | no muscular response to stimulation - very poor prognosis |
| nurse assessment of increased ICP | glasgow coma scale 3-15 (< 9 = coma); change in LOC; unresponsive unequal pupil response (same side as lesion); bp drop (tx w/ IV fluid can incr. ICP); cranial nerve assess; blink reglex (stroke lashes); gag reflex |
| nursing care for altered cerebral tissue perfusion | supine HOB up; neck aligned; avoid severe hip fexion (inc. abdom. pressure); maintain airway (avoid suction); fluid balance; control body temp; monitor glucose; avoid blowing nose; cough;holding breath; monitor ICP; monitor site for infection/leaking |
| how to test for CSF leakage | test for glucose |
| traumatic brain injury | insult to brain that is capable of producing physical, intelectual, emotional, social, & vocational changes |
| when is traumatic brain injury usually seen | with facial, abdominal and musculoskeletal injuries |
| penatraiting skull injury | skull fracture common blunt force; bullet/knife wound |
| complications of penetraiting skull injury | skull fragments can cause laceration of brain tissue, nerves, blood vessels; hematoma common |
| consciousness | complex function controlled by RAS w/ feedback loop |
| 2 criteria of consciousness | wakefulness; awareness (self, environment, time) |
| levels of awareness | confusion; delirium; dementia; disorientation |
| confusion | alteration in thought; attention; comprehension |
| delirium | drug or medical condition induced; often reversible; less able to focus;change in cognition |
| dementia | chronic confusion |
| disorientation | one criteria of confusion; unable to identify self; envoronment; time |
| bacterial meningitis | inflammation of the meninges - usually arachnoid and sub arachnoid s;pace |
| cause of bacterial meningites | almost any bacteria; meningococci; pneumoncocci; haemophilus influenza; skull fracture provide easy entry |
| sx of meningitis | nuchal rigidity (classic Sx); brudzinski sign; kernig sign; photophobia; fever; chill; tachycardia; headache; N&V; petechia/hemorrhagic rash; iritability (early stage); confusion; coma; MEDICAL EMERGENCY |
| tx of meningitis | lumbar puncture; anticonvulsants, IV antibiotics (blood brain barrier is interrupted by inflamm & antibiotics can help |
| lumbar puncture for meningitis | be sure thereis no increased ICP; find elevated pressure, proteins, decreased glucose (bacteria feeds on it), elevated white count = immune response |
| nursing issues w/ meningitis | same as increased ICP; watch for CSF leak from nose or ears, especially w/ skull fracture |
| epidural hematoma | continuous ARTERIAL bleeding between dura & skull (above dura) |
| causes of epidural hematoma | injury to blood vessel; skull fracture |
| signs & sx of epidural hematoma | immediate unconscious (arterial bleed); awakens and is alert (CSF compensation); loss of consciousness w/ rapid decline to coma (compensation fails) |
| subdural hematoma | bleeding between dura & arachnoid |
| cause of subdural hematoma | tearing of bridging VEINS; chronic in alcoholics - brain atrophy, subtle changes |
| sx of subdural hematoma | acute, subacute, chronic, sx w/in 24-48 hrs of injury due to venous bleed; all sx of increased ICP |
| medical management of brain bleeds | support of all organs; ventilatory support; manage fluid balance; nutrition/ GI function; initial mngmnt same for all head injury; sometimes evacuation of clot or blood through burr hole |
| brain death | cessation and irreversibility of all brain function including stem; criteria vary from state to state; no evidence of cerebral or brain function for 6 - 24 hrs; no depressants or alcohol poisoning can be present |
| criteria for brain dealth | unresponsive coma; no motor/reflex movement; no spontaneous respirtions; fixed & dilated pupils; absent ocular response to head turning (doll eyes,no nystagmus w/ caloric test); flat eeg; no cerebral circulation; persistance of sx for 1 hr; 6hrs for coma |
Created by:
aclelan
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