ADULT HEALTH EXAM 2 Study GUIDE

Neurological System Assessment of Neurologic Function (ATI Review)

  • Purpose: Establish baseline neurologic status and detect changes early.

    • Understanding changes in neurologic function is crucial for timely intervention.

Level of Consciousness (LOC)

  • Types of consciousness states based on responsiveness:

    • Alert: Fully awake and responsive.

    • Awake: Generally responsive and aware of surroundings.

    • Lethargic: Drowsy but can be aroused with verbal stimuli.

    • Obtunded: Difficult to arouse and responds slowly.

    • Stupor: A state of near-unconsciousness; responds only to painful stimuli.

    • Coma: Unresponsive and lacks awareness of self and environment.

Glasgow Coma Scale (GCS)

  • Components: Eye opening, verbal response, motor response.

    • Eye Opening (4 points):

    • Spontaneous (4)

    • To speech (3)

    • To pain (2)

    • None (1)

    • Verbal Response (5 points):

    • Oriented (5)

    • Confused (4)

    • Inappropriate words (3)

    • Incomprehensible sounds (2)

    • None (1)

    • Motor Response (6 points):

    • Obeys commands (6)

    • Localizes pain (5)

    • Withdraws from pain (4)

    • Flexion to pain (3)

    • Extension to pain (2)

    • None (1)

  • Interpretation: Score ≤8 indicates severe impairment.

Pupils Assessment

  • PERRLA: Pupils Equal, Round, Reactive to Light and Accommodation. Elements to observe:

    • Size and equality

    • Reaction to light (both direct and consensual)

Motor Function Assessment

  • Strength Rating (0-5):

    • 0: No muscle contraction

    • 1: Flicker of contraction

    • 2: Active movement with gravity eliminated

    • 3: Active movement against gravity

    • 4: Active movement against resistance

    • 5: Normal strength

  • Additional Observations:

    • Drift, gait, coordination

Sensory Function Assessment

  • Examination of sensory modalities:

    • Pain

    • Temperature

    • Vibration

    • Proprioception

Altered Level of Consciousness (LOC)

  • Manifestations:

    • Confusion → lethargy → stupor → coma

  • Causes: Hypoxia, hypoglycemia, stroke, head injury, drugs, infections.

  • Nursing Priorities: Ensure airway, provide oxygenation, check glucose levels routinely, and conduct frequent neuro checks.

Neurologic Dysfunction

Headaches/Migraines

  • Pathophysiology: Changes in neurovascular function, activation of the trigeminal nerve.

  • Types:

    • Tension: Stress-related muscle contraction headaches.

    • Cluster: Severe headaches occurring in cycles.

    • Migraine: Often accompanied by an aura, triggers can vary.

  • Assessment Criteria:

    • Aura, triggers, location, duration, photophobia, nausea.

  • Interventions:

    • Ensure a dark, quiet room, apply cold compresses, administer medications (triptans, NSAIDs).

  • Patient Education: Encourage avoiding known triggers and taking medications at headache onset.

Delirium vs Dementia

  • Delirium:

    • Characteristics: Acute, reversible, fluctuating.

    • Common causes: Infections, medications.

  • Dementia:

    • Characteristics: Chronic, progressive, irreversible (e.g., Alzheimer's disease).

    • Understanding cognitive decline is critical for patient care.

  • Nursing Care for both:

    • Reorientation, safety measures, and treating underlying causes only for delirium.

Seizures/Epilepsy

  • Types:

    • Focal Seizures: Affect only a part of the brain.

    • Generalized Seizures: Include tonic-clonic (characterized by stiffening and rhythmic jerking).

    • Tonic: Muscle stiffness.

    • Clonic: Rhythmic jerking of the body.

  • Nursing Actions During Seizure:

    • Protect the head, position the client on their side, and do NOT restrain the patient.

  • Postictal State: Confusion or fatigue following a seizure.

  • Common Medications: Phenytoin, levetiracetam.

  • Common Causes: Cerebrovascular disease, hypoxemia, childhood fever, head injuries, hypertension, CNS infections, metabolic and toxic conditions, drug and alcohol withdrawal.

Vegetative State / Coma

  • Coma: No arousal or awareness of surroundings.

  • Vegetative State: Sleep-wake cycles present without awareness.

  • Care: Focus on maintaining skin integrity, ensuring adequate airway management, nutrition, and preventing infections.

Cerebrovascular Disorders (Stroke - CVA)

  • Types:

    • Ischemic Stroke:

    • Caused by obstruction due to thrombus or embolism, leading to infarction of brain tissue.

    • Hemorrhagic Stroke:

    • Caused by bleeding into brain tissue, ventricles, or subarachnoid spaces.

  • FAST Assessment:

    • Face droop.

    • Arm weakness.

    • Speech difficulties.

    • Time of symptom onset (critical for treatment).

  • Priority Actions:

    • Conduct a CT scan before anticoagulant administration.

  • Thrombolytic Treatment (tPA): Administer within 3-4.5 hrs for ischemic strokes only; blood pressure must been lower than 135/110 before administration.

  • Nursing Considerations: Swallow screen, aspiration prevention, and mobilization strategies.

Risk Factors for Stroke

  • Nonmodifiable: Age, gender, ethnicity.

  • Modifiable: Hypertension (primary risk factor), cardiovascular disease, elevated cholesterol/hematocrit, obesity, diabetes, oral contraceptive use, smoking, drug and alcohol abuse.

Neurologic Infections / Autoimmune / Neuropathies

Multiple Sclerosis (MS)

  • Pathophysiology: Autoimmune demyelination affecting the central nervous system (CNS) leading to progressive immune-related neurodegeneration.

  • Manifestations: Fatigue, vision changes, weakness.

  • Nursing Management: Managing fatigue, administering corticosteroids during relapse periods, and promoting physical mobility.

Neuropathy

  • Causes: Diabetes mellitus, alcoholism, vitamin deficiencies.

  • Findings: Numbness, tingling, and pain assessments are required.

  • Teaching Points: Importance of foot care and injury prevention.

Bell's Palsy

  • Etiology: Inflammation of cranial nerve VII (facial nerve) leading to unilateral facial paralysis.

  • Care: Ensure eye protection and consider corticosteroid administration to reduce inflammation.

Myasthenia Gravis

  • Pathophysiology: Autoimmune disorder affecting acetylcholine receptors at the neuromuscular junction.

  • Findings: Muscle weakness that worsens with increased activity.

  • Medications: Anticholinesterase agents such as pyridostigmine.

Guillain-Barré Syndrome (GBS)

  • Manifestation: Ascending paralysis, usually following infection (could be viral or bacterial).

  • Priority Consideration: Monitor respiratory status, particularly vital capacity.

Oncologic / Degenerative Neurologic Disorders

Parkinson's Disease

  • Pathophysiology: Degeneration of dopamine-producing neurons in the basal ganglia.

  • Key Symptoms:

    • Cardinal Symptoms: Tremor, rigidity, bradykinesia (slowness of movement), and postural instability.

    • Autonomic Symptoms: May include sweating, drooling, flushing, orthostatic hypotension, gastric retention, and urinary retention.

    • Psychiatric Symptoms: Depression, anxiety, possible symptoms of dementia or delirium.

  • Medication Treatment: Use of Levodopa/Carbidopa to manage motor symptoms.

  • Nursing Assessment Focus:

    • Assessment of degree of disability and tracking functional changes throughout the day, including responses to medication, speech quality, facial expressions, swallowing difficulties, and signs of confusion.

Muscular Dystrophy

  • Description: Group of genetic diseases characterized by progressive weakening and wasting of skeletal and voluntary muscles due to genetic mutations.

  • Inheritance Pattern: Most forms are inherited, with Duchenne muscular dystrophy being the most common and inherited as a sex-linked trait.

  • Care Requirements: Support for respiratory function, mobility assistance, and emotional support for patient and family.

Immunologic / Endocrine System

Assessment of Immune Function

  • Considerations: Document infection history, allergies, and vaccinations.

  • Laboratory Tests: Assess white blood cell (WBC) counts, immunoglobulin levels.

Immune Deficiency Disorders

  • Primary Immune Deficiencies: Congenital conditions noted by recurrent infections.

    • Management: Prevent exposure, consider prophylactic antibiotics as necessary.

Allergic Disorders

  • Anaphylaxis:

    • Description: Represents a life-threatening systemic allergic reaction.

    • Management: Administer epinephrine intramuscularly, secure airway, and ensure oxygen supply.

  • Angioedema:

    • Characteristics: Swelling of lips, tongue, or airway; treat similarly to anaphylaxis when airway involvement exists.

  • Allergic Rhinitis:

    • Symptoms include nasal congestion and sneezing; interventions may include antihistamines and intranasal steroids.

Obesity Management

  • BMI ≥30: Recognized as obesity.

    • Risks Associated: Includes diabetes mellitus (DM), hypertension (HTN), and coronary artery disease (CAD).

  • Nursing Focus: Counseling on nutrition and exercise.

Endocrine Disorders Assessment

  • Key Subject Areas: Weight, heat/cold tolerance, heart rate, laboratory assessments (TSH, T3, T4, calcium levels).

Thyroid Disorders

Hypothyroidism

  • Characteristics: Low metabolic rate leading to fatigue, weight gain, and cold intolerance.

    • Treatment: Administration of Levothyroxine as hormone replacement.

Hyperthyroidism

  • Characteristics: Involving a high metabolic rate causing weight loss, heat intolerance, and tachycardia.

    • Medications for Management: Methimazole and beta-blockers as supportive treatment.

Parathyroid Disorders

  • Hypoparathyroidism:

    • Consequence of low calcium levels leading to tetany; identified by Chvostek's sign.

  • Hyperparathyroidism:

    • Symptoms of high calcium levels include stones, bone pain (the 4 ‘B’s): stones, bones, groans, and psychiatric overtones.

Thyroid Cancer

  • Characteristic signs include a painless neck mass requiring post-thyroidectomy airway monitoring due to potential complications.

Diabetes Mellitus (DM)

Type 1 DM

  • Characteristics: Autoimmune disorder; characterized by absolute insulin deficiency requiring lifelong insulin therapy.

Type 2 DM

  • Characteristics: Characterized by insulin resistance; managed through lifestyle changes and, if necessary, oral medications.

Hypoglycemia

  • < 70 mg/dL signifies low blood sugar; symptoms include shakiness, sweating, and confusion; treatment involves ingested carbohydrates (15 g).

Hyperglycemia

  • Symptoms: Include polyuria, polydipsia, and polyphagia. Long-term complications could involve neuropathy, nephropathy, and retinopathy.

Diabetic Ketoacidosis (DKA)

  • Generally occurs in Type 1 DM, characterized by the presence of ketones, leading to metabolic acidosis.

    • Management: Requires IV fluids, insulin administration, and monitoring electrolytes.

Hyperglycemic Hyperosmolar Syndrome (HHS)

  • Usually indicated in Type 2 DM with significantly elevated glucose levels without the presence of ketones.

Respiratory System Assessment

Respiratory Function Assessment

  • Essential evaluations include assessing the rate, depth, and pattern of breathing; lung sounds; utilizing pulse oximetry and arterial blood gases (ABGs).

Diagnostic Evaluations

  • Standard tests include chest X-rays, CT scans, sputum cultures, and pulmonary function tests (PFTs).

Upper Respiratory Tract Disorders

  • Rhinitis/Viral Rhinitis: Symptoms include congestion and sneezing; the recommended supportive care includes hydration and humidifier use.

  • Rhinosinusitis: Symptoms involve facial pain and pressure; treatment may involve decongestants and antibiotics if there is a bacterial origin.

  • Epistaxis: Management should include leaning forward and pinching the nose.

  • Pharyngitis/Tonsillitis/Adenoiditis: Symptoms encompass sore throat and fever; antibiotics should be administered if streptococcal infection is confirmed.

Laryngeal Disorders

  • Laryngitis: Symptoms entail hoarseness; prescribe voice rest for relief.

  • Obstructive Sleep Apnea: Characterized by airway collapse during sleep; manages with CPAP therapy.

Tracheostomy Consideration

  • Basic Management: Requirements include maintaining airway patency, ensuring suctioning abilities, and having emergency equipment at the bedside. Suctioning should be performed post-surgery and humidified air should be administered.

Lung Disorders

  • Aspiration Risk: High-risk populations include stroke victims and individuals with decreased LOC; preventive strategies must be established.

  • Acute Tracheobronchitis: Typically causes cough and sputum production, commonly viral in origin.

  • Pneumonia: Presents with fever, cough, and crackling lung sounds; treatment consists of antibiotics and utilization of an incentive spirometer.

  • Sarcoidosis: Considered a granulomatous disease; treatment often involves corticosteroids.

  • Lung Cancer: Associated with symptoms such as persistent cough and hemoptysis.

Chronic Pulmonary Disease

  • COPD: A composite of chronic bronchitis and emphysema; smoking cessation is critical alongside bronchodilators for therapeutic benefit.

  • Asthma: Recognized as reversible airway inflammation and treated with both rescue (e.g., albuterol) and controller medications (e.g., inhaled corticosteroids).

Cystic Fibrosis

  • Characteristics: The disorder involves thick mucus production resulting in frequent respiratory infections.

  • Management: Chest physiotherapy and pancreatic enzyme supplementations are vital; bronchodilators should be administered prior to chest physiotherapy to optimize treatment efficiency.