Concepts of Adult Health Nursing: Exam 2 Definitive Study Guide

Intracranial Pressure (ICP) Pathophysiology and Manifestations

• Definition of ICP: ICP is the pressure growing on the inside of the skull. This is often caused by factors such as:     * Swelling of the brain (often resulting from brain or head injury).     * Increase in Cerebrospinal Fluid ($\text{CSF}$).     * Bleeding from the brain.
• Primary Sign and Symptom: The single most critical sign is a change in level of consciousness.
• Diagnostic Testing for ICP:     * Glasgow Coma Scale (GCS): Assesses neurological status based on three criteria:         * Eye Opening: Do they open their eyes when you come into the room?         * Verbal Response: Are they oriented when talking without slurring words?         * Motor Response: Do they obey commands (e.g., "Can you wiggle your toes?")?     * Physical Exam: Focuses on posturing, level of consciousness, and pupil reaction.     * Imaging Order:         * $1^{st}$—CT Scan.         * $2^{nd}$—MRI.     * Electroencephalogram (EEG): Used to assess electrical activity.     * Cushing’s Triad: (Specific symptoms indicative of increased pressure, mentioned as a key concept).
• Abnormal Posturing Patterns:     * Decorticate Posturing: The patient flexes inward toward the center of the body. An easy way to remember this is: "Flex in; you want to cuddle the cats on your chest."         * Arms bent toward the center of the body.         * Curled wrists and balled hands against the chest.         * Rigid, extended legs.         * Pointed and turned-in toes.     * Decerebrate Posturing: The patient flexes outward and away from the body. An easy way to remember this is: "Flex out; you want the brat away from your body."         * Arms parallel to the body.         * Straight, tense wrists.         * Curled fingers.         * Rigid, extended legs.         * Pointed and turned-in toes.
• Lumbar Puncture (LP) Contraindication: NO LUMBAR PUNCTURE WITH ICP. Removing fluid can cause brain herniation due to the pressure gradient.

Clinical Management of Increased Intracranial Pressure

• Environmental Controls: Maintain a calm, peaceful room away from loud noises or bright lights.
• Patient Positioning: Position the patient in a semi-Fowler's position ($35-45^\text{o}$) with the head kept midline.
• Surgical Intervention: Craniotomy involves the removal of a part of the skull to release pressure.
• Pharmacological Interventions:     * Mannitol:         * Classification: Diuretic.         * Mechanism of Action: If working correctly, there will be an increased urine output.         * Adverse Effects: Seizures and tachycardia.     * Decadron:         * Classification: Corticosteroid.         * Side Effect: Increased glucose levels.         * Adverse Effects: Heart failure, thrombocytopenia, and angioedema.

Cerebrovascular Accident (Stroke)

• Definition: A medical emergency where a blood vessel in the brain is either blocked by a clot or has burst.
• Classification of Strokes:     * Ischemic Strokes ($87\%$):         * Thrombotic: The clot forms directly within the vessel in the brain.         * Embolic: A "wandering" clot that formed elsewhere in the body and traveled to the brain.     * Hemorrhagic Stroke ($13\%$): A bleed in the brain resulting from a ruptured blood vessel.
• Emergency Assessment (BE FAST):     * B—Balance.     * E—Eyes.     * F—Face.     * A—Arms.     * S—Speech.     * T—Time.
• Risk Factors:     * Non-modifiable: Age, Race, Gender, Hereditary factors, and history of previous strokes.     * Modifiable: Diabetes, Hypertension, Obesity, Sedentary lifestyle, bad diet, Heart disease, Smoking, excessive alcohol intake, and Hyperlipidemia.
• Signs and Symptoms by Type:     * Hemorrhagic: Characterized by the "worst headache ever," stiff neck, loss of consciousness, and seizures.     * Ischemic: Characterized by one-sided weakness, visual issues, confusion, headache, and dysphagia (difficulty swallowing).
• Diagnostic Battery:     * CT scan with contrast.     * MRI.     * EEG.     * Cerebral and carotid angiography.     * Carotid ultrasound.     * ECG/EKG.     * Blood studies: Lipid panel and PT/INR (to determine how fast blood clots).

Medical and Nursing Management of Stroke

• Thrombolytic Therapy (tPA):     * Often called a "Clot Buster."     * Timeline: Must be administered within $3\,hours$ to dissolve clots.     * Indication: Only used for acute Ischemic strokes.     * Route: Administered IV.     * Prerequisite: CT and MRI must be performed first to confirm there is no hemorrhage.
• Anticoagulant Therapy: Warfarin (Coumadin):     * Adverse Effects: Hemorrhage, hematuria, and Hepatitis.
• Rehabilitative Therapies:     * Occupational Therapy (OT).     * Physical Therapy (PT).     * Speech Therapy: Includes a swallow evaluation for gag reflex and aspiration risk. Note: No straws should be used for patients with dysphagia.
• Patient Transfer: Always hold the patient on their strong side. Remember to lock the wheelchair.

Neurological Disorders: Multiple Sclerosis, Dementia, and Delirium

• Multiple Sclerosis (MS):     * Nature: A chronic, progressive, and degenerative autoimmune disease.     * Prevalence: Second most common neurological cause of disability; predominantly affects women between $20-40\,years$ old.     * Diagnostics: MRI of the brain and spinal cord, based on patient history and clinical manifestation.     * Management: There is no cure. Treatment focuses on symptom management and support.     * Pharmacology for MS:         * Corticosteroids: For inflammation.         * Baclofen/Tizanidine: For muscle spasms.         * Copaxone: For myelin sheath attacks; slows MS symptoms.         * Gabapentin: For neuropathic pain.         * Amantadine: For fatigue relief.
• Dementia and Alzheimer’s: Slow, progressive diseases that impair memory and decision-making.
• Delirium: A rapid onset of confusion and altered state of consciousness, usually due to an underlying cause such as infection.
• Dementia Nursing Care:     * Encourage independence, but safely.     * Remove from overstimulating environments.     * Keep familiar objects with the patient.     * Maintain continuity of care (consistent staff).     * Use a big clock and calendar for orientation.     * Keep patients active during the day; provide a warm bath before bed.     * Low stimuli at night (no TV, use night lights).     * Weight loss is common; keep them centered while eating to maintain focus.     * Validation Therapy: Once dementia is profound, do NOT reorient as it causes confusion. Validate their feelings and "play along" while keeping them safe.

Meningitis and Encephalitis

• Meningitis: Infection of the meninges of the brain (viral or bacterial). Characterized by a rapid onset of signs and symptoms.     * Signs and Symptoms: Fever, vomiting, drowsiness, confusion, irritability, severe muscle pain, pale/blotchy skin (spots and rash), severe headache, stiff neck, photophobia (dislike of bright lights), convulsions/seizures.     * Clinical Tests: Positive Kernig and Brudzinski signs.     * Diagnostics: Lumbar Puncture (requires informed consent), CT Scan, MRI, Throat Culture.     * Treatment (Bacterial): Prompt recognition, broad-spectrum antibiotics (until CSF results are obtained), and isolation (Contact Precaution: DROPLET).     * Treatment (Viral): Rest, increased fluids, and medications for fever/headache.
• Encephalitis: Inflammation of the entire brain, typically viral. Often transmitted by bug bites, but can follow measles, mumps, or chickenpox. Characterized by a slow onset.     * Signs and Symptoms: Fever, stiff neck, nausea, abdominal pain, weakness, and seizures.     * Treatment: Safety precautions (high seizure risk), comfort medications, and physical therapy for strength.

Seizure Disorders and Status Epilepticus

• Definition: Sudden change in behavior caused by electrical hyperactivity in the brain. Can lead to permanent neurological damage due to depletion of oxygen and glucose stores.
• Nursing Priorities: SAFETY AND DOCUMENTATION.
• Causes: Trauma, reduced cerebral perfusion, infection, electrolyte disturbances, tumors, genetic tendency, and epilepsy.
• Classification:     * Focal: Localized to one area.     * Tonic-Clonic: Formerly known as "Grand Mal."     * Myoclonic: Uncontrolled muscle movement.     * Absent: Characterized by "staring off into space."
• Status Epilepticus: A medical emergency defined as a seizure longer than $5\,minutes$ or multiple seizures without returning to consciousness.     * Initial Meds: Diazepam and Ativan.
• Seizure Medications (Anticonvulsants):     * Phenytoin (Dilantin).     * Carbamazepine (Tegretol).     * Valproic Acid (Depakote).     * Levetiracetam (Keppra).     * Lorazepam (Ativan).     * Safety Rule: Do NOT stop anticonvulsants abruptly.
• Seizure Precautions: Low, padded bed; suction and oxygen at bedside; clear airway; lay patient on their side if seizing. Patients should sit down immediately if they feel "weird."

Diabetes Mellitus Type 1 and Type 2

• Diabetes Type 1:     * Nature: Autoimmune; rapid onset.     * Requirement: Insulin is REQUIRED for life.     * Signs and Symptoms: The 3 Ps (Polyuria, Polyphagia, Polydipsia), weight loss, weakness/fatigue, and hyperglycemia.
• Diabetes Type 2:     * Nature: Slow onset; often associated with a sedentary lifestyle.     * Signs and Symptoms: Polyuria, polydipsia, weight gain or loss, and blurred vision.     * Management: Nutritional changes, exercise, and oral medications (Metformin, Ozempic, etc.) or insulin.
• Metabolic Syndrome (Precursor to Diabetes):     * Signs: Impaired glucose tolerance, high serum insulin, hypertension, low HDL, and elevated triglycerides.

Insulin Classifications

• Special Note on Short-Acting: Only Regular insulin (Humulin R/Novolin R) is used for IV administration.
• Mixing Insulins: The sequence is Cloudy → Clear → Clear → Cloudy (Injection of air into NPH, then air into Regular, then drawing Regular, then drawing NPH).

Diabetes Management and Complications

• Hypoglycemia Management (15-15 Rule):     * Consume $15\,g$ of carbohydrates.     * Check blood glucose after $15\,minutes$.     * Repeat until blood glucose is approximately $70\,mg/dL$.     * Once stable, eat a meal with protein and fat to maintain levels.
• Exercise: Always check sugar before exercise (it can drop glucose) and carry a snack.
• Laboratory Indicators:     * BUN/Creatinine: Increased BUN with normal Creatinine indicates dehydration. Both increased indicates kidney problems.     * Diagnostic Tests: A1C, Fasting Blood Glucose, Glucose Tolerance Test (GTT), Random Blood Sugar, Urinalysis, and GAD (specific to Type 1).
• Monitoring Parameters: Cholesterol, Lipids, Blood Pressure, and Blood Glucose.
• Long-Term Complications:     * Microvascular: Nephropathy (kidneys), Neuropathy (nerves), Retinopathy (eyes).     * Macrovascular: Heart attack, stroke, peripheral vascular disease.
• Diabetic Foot Care:     * Cut toenails straight across.     * Do not soak feet in hot water.     * Check and wash feet daily.     * Wear socks or shoes at all times (no bare feet).     * Buy shoes at the end of the day (EOD) when feet are largest.

Diabetic Pharmacology

• Insulin Agents: Lispro (Humalog), Aspart (Novolog), NPH (Humulin/Novolin N), Glargine (Lantus), Degludec.
• Glucagon: Specifically used to increase blood sugar in emergencies.
• Metformin: An anti-diabetic used to help with high blood sugar.
• Glipizide: Stimulates the pancreas to release/produce more insulin.
• Empagliflozin: Helps the kidneys prevent the absorption of blood sugar.
• Semaglutide: Helps control blood sugar.