Chronic Exam 3

TIA – Transient Ischemic Attack

TIA are a brief interruption in cerebral blood flow, lasts about only a few minutes but have the same signs as a stroke. A TIA puts the pt at a higher risk of having another TIA or stroke, treatment is the prevention of another stroke and the longer a TIA lasts the higher the risk of a stroke.

Stroke/CVA

stroke (brain attack) is a change in normal blood supply to the brain; hypertension is the main cause

Ischemic, Thrombotic, Embolic, Hemorrhagic

Ischemic = the type of stroke that occurs when the blood flow to the brain is interrupted or reduced. Two types of ischemic = THROMBOTIC: most common and caused by plaque build up, and EMBOLIC: occurs when an clot dislodges from another location and it travels to the brain making a blockage causing the stoke
Hemorrhagic = This occurs when there is bleeding in or around the brain that cuts off the blood supply. This could be caused by an aneurysm, fall or AV malformation

Fibrinolytic therapy – eligibility for – what drug is used – what would be a positive outcome of the therapy

Medication used to dissolve the blood clots that have caused the blockage. Should be given within 3 to 4 hours after the onset of a stroke.
There are criteria that this therapy should not be used for and this includes: over 75, prior bleeding in the brain or recent active bleeding, trauma, or surgery, a history of stroke in the past three months, have a known brain tumor, have uncontrolled hypertension
A positive outcome would that it restores blood flow to the brain and that there are minimal residuals (effects that result from and persists after strokes)

Dysphagia – definition – problems associated with – nursing interventions

Dysphagia = difficulty swallowing. This can lead to aspiration which could cause aspiration pneumonia or even death. The nurse should therefore assess the patients ability to cough, or perform other screening tools for dysphagia

Right hemisphere CVA – symptoms

Left sided weakness, denial of the paralysis or impairment, visual problems (specifically left sided), spatial problems, inability to localize body parts, memory problems

Left hemisphere CVA – symptoms

Right-sided weakness paralysis or sensory issues, speech and language issues, inability to read or write, inability to do math, organize, reason, and analyze problems

SAH – sub arachnoid hemorrhage

SAH = more common than other types of hemorrhagic strokes, results from bleeding into the subarachnoid space (the space between the Pia mater and arachnoid layers of the meninges covering the brain)
This type of bleeding is usually caused by an aneurysm or arteriovenous malformation (AVM)

Vasospasm – what is it, how might it be treated

Vasospasm = occurs as a result of a sudden and periodic constriction of a cerebral artery, often following a SAH or bleeding from an aneurysm or AVM rupture. This constriction interrupts blood flow to the areas of the brain. Reduced perfusion from vasospasm contribute to secondary cerebral ischemia and further neurological development

Ataxia

Ataxia = impaired balance or coordination

A/V malformation

an angled collection of malformed, thin-walled, dilated vessels without a capillary network. An abnormal tangle of blood vessels connecting arteries and veins disrupts normal blood flow and oxygen circulation.
It is uncommon and occurs during embryonic development

Aneurysm

Aneurysm = an abnormal ballooning or blister along a normal artery commonly developing in a weak spot on the artery wall. Larger ones are more likely to rupture than a small one

Reception, Perception, Reaction

Reception = process of receiving data about the external or internal environment through the senses
Perception = the conscious process of selecting, organizing, and interpreting data from the senses into meaningful information
Reaction =

Atherosclerosis

Atherosclerosis = the thickening or hardening of the arteries caused by a buildup of plaque in the lining of an artery

Sensory changes and the older adult

Sensory function tends to decline progressively throughout adulthood as the result of aging or chronic illness. Adults may experience the need to compensate for the loss of one type of stimulation by increasing other sources of sensory stimuli. Touch becomes increasingly important as we age.

Social isolation

Aphasia – receptive, expressive, mixed, global

Aphasia = language disorder that affects a persons ability to communicate
Receptive: can say words but what they are saying does not make sense, usually have trouble understanding what is being said (wernickes)
Expressive: difficulty forming sentences, leaves out words. (brocas area)
Mixed: sparse and effortless speech (like brocas) but also has trouble understanding it (wernickes)
Global: trouble both understanding and forming words and sentences

Meds that may alter hearing

Examples of medications that are ototoxic and can impair auditory function if taken over a long period of time include furosemide, some cancer chemotherapies, and aspirin. Be sure to review patients medication records when assessing for sensory alterations.

Nursing diagnosis r/t sensory alterations

Acute confusion, risk for acute confusion, chronic confusion, and impaired memory

Sensory overload

Occurs when a person experiences so much sensory stimuli that the brain is unable to either respond meaningfully or ignore the stimuli. The person feels out of control and may exhibit all of the manifestations observed in sensory deprivation (perceptual, cognitive, and emotional responses). The amount of quality of stimuli necessary to produce overload my differ greatly from one person to another and is influenced by factors such as age, culture, personality, and lifestyles

Communicating with patients with sensory deficits

Awareness of the patients sensory deficits is necessary to determine whether the patient is able to compensate for the deficit. Illness and hospitalization may threaten a patients usual adaptive patterns and require new self-care abilities. Patients with evolving deficits will require assistance with coping and learning to compensate skillfully

Stereognosis

Perception of solidity of objects

Know the different types of seizures discussed in class, what happens during each seizure.

Generalized: Grand Mal = has two stages, first is loss of consciousness then there is muscle contractions; tonic = sudden tension or stiffness; clonic = rhythmic jerking motion; myoclonic = brief jerking and shock like contraction of the muscles; atonic = muscles suddenly become limp
Partial: complex = when there is an impairment in consciousness; simple = when there is no impairment in consciousness then it is simple
Unclassified (make up a half of seizure) pts tend have an aura before it

Safety measure to take when patient experiencing a seizure

Turn the patient on the side to avoid aspiration, time the seizure and the post-ictal phase and try and observe causes
Not much can be done during the seizure except both trying to protect the patient and yourself

What are seizure precautions?

Seizure precautions = precautions taken to prevent the patient from injury
They vary depending on the health care agency policy (oxygen, suction equipment, airway, IV access, and side rails up and padded)

Medications – Aricept, Namenda – mechanism of action

No drug can cure it but may help memory and awareness and treating AD symptoms.
Aricept: is an acetylcholinesterase inhibitor and works to increase the acetylcholine levels in the brain. Acetlycholinesterase is an enzyme that breaks down acetylcholine and the drug works by blocking the action of the enzyme
Namenda: is an NMDA antagonist. It selectively blocks the excess amounts of the neurotransmitter glutamate which can damage nerve cells.

Validation therapy

For the patient in late stages of AD or dementia, reality orientation does not work and often increases agitation. Instead use validation therapy which is when the staff member recognizes and acknowledges the patients patients feelings or concerns

Nonpharmacologic management

Managing chronic confusion, preventing injury, community based care, managing care giver strain

Promoting safety for the community dwelling Alzheimer’s patient

Remove or secure all potentially dangerous objects. Late in the ideas seizures could occur, so teach caregivers how to prevent injury when a seizure occurs. Talk calmly and softly attempting to redirect patients. Use calm positive statements and reassure the patient that they are safe. Provide a diversion

Caregiver role strain

When the caregiver feels they may not be able to perform their job adequately because of financial burdens, increased responsibility, a change in family life, or role change

Effects of changes in environment

Likely to increase the patient confusion and could possibly increase the risk for injury

Stages of Alzheimer’s disease

Early (mild) or stage 1 (first symptoms up to 4 years): independent in ADLs, denies symptoms are present, forgets names, and misplaces items, short-term memory loss and forgets new information, subtle personality and behavioral changes.
Middle (moderate) or Stage 2 (2 to 3 years): impairment of all cognitive functions, demonstrates problems with handling money or finances, is disoriented to time, place, and event, is possibly depressed and/or agitated, speech and language deficits
Late (severe) or stage 3: completely incapacitated; bedridden, totally dependent in ADLs, haps loss of mobility and verbal skills, has agnosia, possible seizures and tremors

Hyperflexion, Hyperextension, Axial Loading injuries

Hyperflexion: sudden and forceful acceleration of the head forward, causing extreme flexion of the neck, often caused by a head on motor vehicle collision or a diving accident
Hyperextension: The head is suddenly accelerated and then decelerated. occurs most often in vehicle collisions in which its struck from behind or during falls when the patients chin is struck.
Axial loading: axial loading is vertical compression. results from diving accidents or a jump when a person lands on their feet

Penetrating trauma

Is classified by the speed of the object (knife, bullet) causing the injury. Low speed or low impact causes damage directly at the site or local damage to the spinal cord or spinal nerves. High speed causes both direct and indirect damage.

Review “Key Assessment Findings” on the person with SCI. i.e. neurologic system, cardiovascular system, respiratory system and gastrointestinal system.

Neurologic: the neurologic level is determined by the zones of sensory and motor function known as dermatomes
Cardiovascular: dysfunction results from the disruption of the sympathetic fibers of the ANS, especially if the injury is above the 6th thoracic vertebrae. Bradycardia, hypotension, and hypothermia occur because of loss of sympathetic input. Can lead to cardiac dysrhythmias.
Respiratory: a patient with cervical SCI is at risk for breathing problems resulting from an interruption of spinal innervation to the respiratory muscles. May have to work closely with respiratory therapists
GI: Assess the patients abdomen for symptoms of internal bleeding such as abdominal distention, pain, or paralytic ileus. Monitor abdominal pain and changes in bowel sounds. After the first few days, when edema subsides, the spinal reflexes that innervate the bowel and bladder usually begin to establish function, depending on the level of the injury.

Review those involved with recovery, i.e, MD, RN, OT, PT

What is spinal shock? Signs, symptoms?

Spinal shock: occurs immediately as the cords response to injury. The patent has complete but temporary loss of motor, sensory, reflex, and autonomic function that often lasts less than 48 hours but may continue for several weeks.