Exam 1 Flashcards
Parkinson’s disease is a
chronic, terminal/fatal disease
Dopamine levels are __________ and acetylcholine levels are __________ in patients with Parkinson’s disease.
low; high
Acetylcholine levels are normal, but in relation to dopamine levels they are considered high.
What is the cause of Parkinson’s disease?
The cause is unknown. There could be a genetic or environmental factor.
What are secondary causes of Parkinson’s disease?
Antipsychotic drugs, tumor, or trauma (pseudo Parkinson sx)
Antipsychotic drugs drop dopamine levels; taking pts off meds will stop sx
Parkinson’s disease affects motor, cognitive, and ADL function.
True or false?
True
Parkinson’s disease are at an increased risk for falls and injury?
True or false?
True
Symptoms of Parkinson’s disease
-mask-like, blank expression
-pill rolling tremors (occurs most often at rest)
-loss of normal arm swing while walking
-shuffling, propulsive gait
-muscle rigidity (increased resistance to passive movement)
-cog wheel, jerky slow movement
-bradykinesia
-drooling
Risk factors for Parkinson’s disease
Onset between 40-70yo, male, possible predisposition, exposure to toxins/antipsychotic meds
Brain autopsy of patient with Parkinson’s disease reveals
lewy bodies and neuronal loss in the substania nigra
How is Parkinson’s disease diagnosed?
Providers diagnose by ruling out other diseases
Stages of Parkinson’s disease
Stage 1 through 5
Stage 1 is mild
Stage 5 is completely dependent
Medications used to treat Parkinson’s disease increase dopamine and decrease acetylcholine.
True or false
True
Dopaminergics
Trigger dopamine receptors to function
Ex: Levodopa-carbidopa
What does Levodopa do? What does Carbidopa do?
Levodopa is converted into dopamine. Carbidopa is used to decrease breakdown and help levodopa cross blood brain barrier.
How long do dopaminergics work? What is the next step?
Dopaminergics stop working after 5 years of use. Start addressing acetylcholine levels.
What medication is used to treat tremors in pts with Parkinson’s diease?
Triexphenidyl/Benztropine
What side effects should you look out for with Triexphenidyl/Benxtropine?
Monitor for dry mouth, constipation, urinary retention, and possible confusion.
Triexphenidyl/Benztropine has DRYING effects.
What Catechol-O-methyltransferase (COMT) inhibitors is taken with Levodopa and why?
Entacapone
Only taken w/ Levodopa to decrease the breakdown of Levodopa.
MAO-B inhibitors are last resort because they interact w/everything. Increases dopamine. What foods should the patient avoid?
Foods with tyramine
Pts with Parkinson’s disease take antivirals to stimulate the release of dopamine and prevent its reuptake. What is a common antiviral taken by these pts?
Amantadine
What procedures are completed when PD pts do not respond to meds?
Ablative procedures (thalamotomy, pallidotomy), deep brain stimulation, and cell transplantation
Possible complications for PD pts & nursing care
Aspiration pneumonia
-Swallowing precautions, diet per speech therapy, maintain weight, high protein supplements
Altered cognition/mobility
-Provide safe environment
-PD pts require more time to complete tasks (walking, answering questions)
Huntington’s disease is a
Chronic, terminal/fatal disease
Is there a cure for Huntington’s disease?
no
Is Huntington’s disease hereditary?
yes, autosomal dominant
Risk factors for Huntington’s disease
genetics, Caucasian, 30-50yo (male or female)
This disease has an imbalance of dopamine, GABA, and glutamate from the basal ganglia.
Huntington’s disease
The earlier the sx associated with Huntington’s disease present; the more severe the disease is. Death will be sooner.
True or false
True
How quickly can juvenile sx cause death in HD?
within 10 years
Symptoms of Huntington’s disease
-progressive dementia, personality changes, mood swings, depression
-slurred speech, difficulty swallowing, weight loss
-Choreiform movements (uncontrolled, rapid movements/unsteady gait when sitting still)
Diagnostic testing for Huntington’s disease
Genetic testing, CT for frontal horn enlargement, MRI, and PET scan
Is there any neuroprotective/neurorestorative treatment available for Huntington’s disease?
No. Only supportive and symptomatic treatments.
Medications used for Huntington’s disease
-Tetrabenazine to suppress involuntary chorea movements. S/E include new or worsening depression, drowsiness, nausea, restlessness
-Other antipsychotics for psych sx
Possible complications for HD pts & nursing care
Complications: Decisional conflict r/t having children, aspiration pneumonia, altered cognition and mobility
Nursing care: Suicide prevention, encourage planning for residential and EOL care
Amyotrophic Lateral Sclerosis/ALS is also known as
Lou Gehrig’s Disease
Stephen Hawking had this disease.
ALS is a
chronic, progressive neurodegenerative disease
Is there a cure for ALS?
No
Is ALS fatal?
Yes. Most die within 3-5 years from start of sx.
ALS targets the CNS and brain. There is a loss of
voluntary movement control and weakness
What causes ALS?
the cause is unknown
Risk factors for ALS
more common in men, 40-60yo
Symptoms of ALS
Causes progressive muscle weakness and wasting. Clients lose the ability to speak, eat, and eventually breathe (paralysis of respiratory muscles).
Muscle atrophy, muscle weakness, dysarthria (uncoordinated speech), and dysphagia (difficulty swallowing)
What medications do ALS pts take & why?
Riluzole to decrease GABA and
Edaravone to reduce oxidative stress
ALS complications
Death anxiety r/t impending progressive loss of function leading to death
Nursing care for ALS pts
Palliative care for symptom management
Ex: Home health, EOL care
Multiple Sclerosis/MS is a
chronic, progressive, neurodegenerative disease
Autoimmune inflammatory as well
Is there a cure for Multiple Sclerosis/MS?
no
Do pts with Multiple Sclerosis/MS have a shorter lifespan?
No. They have a normal lifespan.
Risk factors for Multiple Sclerosis/MS
Women 2x greater risk than men, 20-50yo, whites of northern European ancestry
Disease that targets the brain & spinal cord (myelin sheath). Demyelination of white matter leads to decreased flow of nerve impulses.
Multiple Sclerosis/MS
Symptoms of Multiple Sclerosis/MS
-intention tremors
-fatigue
-diplopia
-Uthoff’s sign
-Nystagmus
-tinnitus
-decreased sexual function
-gait changes
-muscle spasticity
Over time can lead to tetraplegia (quadriplegia)
What causes Multiple Sclerosis/MS?
the cause is unknown
What can make Multiple Sclerosis/MS symptoms to worsen?
Symptoms worsen in extreme heat & cold, stress, infection, fatigue, and pregnancy
What medications do MS pts take?
-Interferon beta 1a and beta 1b (Causes flu like sx)
-Baclofen, dantrolene, diazepam (muscle relaxants)
-Medical marijuana to decrease pain, stiffness, and spasticity
-Dalfampridine to improve walking/gait
-Dexamethasone is a steroid to manage relapses (Increased risk of infection)
Why should MS pts avoid fatigue and overheating?
To minimize exacerbations
-If exacerbations are minimized, pt can live a relatively normal life
-w/ every exacerbation, MS gets worse
What does CSF of MS pts reveal?
CSF reveals elevated protein levels & slight increase in WBCs
What does a MRI of MS pts reveal?
MRI reveals plaques of the brain and spine
Evoke potential testing for MS pts
Give stimulation and see if sense is decreased
What is the cause of migraines?
Many triggers including genetics
Patho of migraines
Cerebral artery vasodilation –> prostaglandins released –> brain tissue inflammation
Symptoms of migraines
- Photophobia and phonophobia (sensitivity to sounds)
- Nausea and vomiting
- Stress and anxiety
- Unilateral pain, often behind one eye or ear
- Health history and family history for headache patterns
- Alterations in ADLs for 4-72 hr
- Manifestations that are similar with each headache
Three types of migraines
Migraine w/aura (classic migraine)
Migraine w/o aura (common migraine)
Atypical migraine
- Prodromal stage: Aware it’s coming, irritated, food cravings, depressed
- Aura stage: minutes to hours, n & t of face, mouth, acute confusion, vision problems (light flashes, bright spots)
- Second stage: Severe, throbbing, incapacitating HA
- Third stage (4-72hr): Dull HA
- Recovery: Pain & Aura subsiding, increased muscle spasms & myalgia
- Older adult: Visual Migraine, Aura w/o pain
Migraine w/aura (classic migraine)
- Pain is aggravated by physical activity.
- Unilateral, pulsating pain.
- One or more manifestations present: photophobia, phonophobia, N/V
- Persists for 4-72 hr. Often occurs in early AM, during stress, or with premenstrual tension or fluid retention.
Migraine w/o auro (common migraine)
- Status migrainous: >72hrs
- Migrainous infarction: Neuro sx for > 7 days, imaging may show ischemic infarct.
- Unclassified: Does not fit other criteria
Atypical migraine
Risk factors of migraines
All ages, women affected more than men. May be associated with other conditions like colds, allergies, stress, low BS, or muscle tension.
Migraine sufferers are at r/f stroke & epilepsy.
What are preventative options for migraines?
-NSAIDS
-Beta Blockers-Take even when asymptomatic for prevention to prevent vascular changes.
-Botox
Migraine abortive therapy options during aura or soon after aura begins
-NSAIDS (ibuprofen), Tylenol (acetaminophen),
-Antiemetics: Reglan (metoclopramide)
For Severe migraines
-Triptans: produce vasoconstrictive effect
Imitrix (sumatriptan) contraindicated in heart disease
-Ergotamine preparations with caffeine: vasoconstriction & decreases inflammation
Complications & nursing care for migraines
- Focus on pain mgmt during HA (dark environment, HIB elevated, meds)
- HA diary for patterns & triggers
- Trigger avoidance
- Avoid foods with tyramine (pickles, caffeine, beer, wine, ages cheese, artificial sweeteners) & foods with MSG
- Manage anger & conflict
- Avoid glare & flickering lights
- Adequate sleep/rest
- Avoid environmental triggers like odors, perfumes, & tobacco smoke
- Yoga, meditation, exercise, acupuncture, external trigeminal nerve stimulator (wearable head band that stimulates branches associated with HA (not to be used for >20min/day)
Systemic Lupus Erythematosus (SLE) is a
chronic, progressive autoimmune disorder
Lupus exacerbations accelerate
organ damage
What is the cause of Lupus?
Genetic susceptibility not clearly identified. Triggers include infection, injury, drugs, hormones, and exposure to environmental substances, esp. UV light.
Most common cause of death in Lupus pts
CKD and CV impairment
Symptoms of Lupus
Onset of sx is slow. Avg time from initial mild sx to actual dx is 6 years.
- Chronic fatigue
- Recurrent fevers with unknown origin
- Persistent joint & muscle pain, swelling, tenderness, weakness
- Alopecia
- Blurred vision
- Pleuritic pain, pericarditis (pericardial friction rub)
- Anorexia/weight loss, anemia
- Depression
- Butterfly rash
- Raynaud’s phenomenon
Risk factors of Lupus
- Present in women (30-44yo initial dx) 10x more frequently than men
- Incidence declines in females following menopause which suggests estrogen (childbearing years) as a trigger
- African Americans compared to whites in 8:1
Labs and diagnostics of Lupus
- Skin Biopsy – used in dx. Lupus cells & cellular inflammation is seen.
- Antinuclear antibodies (ANAs) - (+) titers in 95% of clients
- ESR – inflammatory biomarker, elevated
- BUN/Creat – Increased with kidney involvement
- UA – protein, casts, & RBCs (kidney involvment)
- CBC – pancytopenia
Medications for Lupus pts
- NSAIDs: used to reduce inflammation/pain. Contraindicated with kidney disease.
- Corticosteroids: prednisone used for inflammation & immunosuppression. Monitor fluid status for fluid retention, HTN, impaired kidney function. Do not stop abruptly, must taper dosage. Risk for fracture. Watch for hyperglycemia.
- Immunosuppressant agents: DMARDs (methotrexate), belimumab, azathioprine. Monitor for infection secondary to immunosuppression. Monitor liver enzymes (AST/ALT)
- Antimalarial: hydroxychloroquine used to suppress synovitis, fever, & fatigue.
Education to provide to Lupus pts
- Wear a wide‐brimmed hat, long‐sleeve shirt, and long pants when outdoors.
- Avoid UV and prolonged sun exposure. Use sunscreen when outside and exposed to sunlight.
- Use mild protein shampoo and avoid harsh hair treatments.
- Use steroid creams for skin rash.
- Report peripheral and periorbital edema promptly.
- Report evidence of infection related to immunosuppression.
- Avoid crowds and individuals who are sick, because illness can precipitate an exacerbation.
- Understand the risks of pregnancy with lupus and treatment medications.
Obstructive Sleep Apnea is defined as
Breathing stops during sleep for greater than 10 seconds and at least 5 times/hr
Apnea leads to __________ gas exchange (hypoxemia), __________ blood CO2 levels (hypercapnia), __________ pH causing the sleeper to wake up & correct obstruction. Cycle repeats throughout the night.
Apnea leads to decreased gas exchange (hypoxemia), increased blood CO2 levels (hypercapnia), decreased pH causing the sleeper to wake up & correct obstruction. Cycle repeats throughout the night.
What is the cause of OSA?
Upper airway obstruction by the soft palate or tongue
Expected OSA findings
-snoring
-excessive daytime sleepiness
-inability to concentrate
-irritability
-bedwetting or excessive urination at night
-reduced sex drive
-fatigue
-depression
-pharyngeal edema
-Chronic OSA: increased risk of HTN, stroke, cognitive deficits, weight gain, DM, pulmonary and CV disease
OSA risk factors
obesity, large uvula, short neck, smoking, enlarged tonsils or adenoids, oropharyngeal edema
Diagnostics for OSA
-STOP Bang Sleep Apnea questionnaire
-Pulmonary function tests (PFTs)
-Overnight sleep study (Polysomnography)
Meds for OSA
Modafinil
Not the first line of therapy. Promotes daytime wakefulness. Does not treat OSA cause. May also help pts with narcolepsy.
Surgical management of OSA
Adenoidectomy, uvulectomy, or uvulopalatopharyngoplasty
Severe cases may need trach
Non-surgical management of OSA
Change of sleep position, weight loss, decrease alcohol use, positive pressure ventilation, avoiding sedating meds, breathing machines
Bilevel airway pressure - More pressure when breathing in, less pressure when breathing out
BiPAP
Continuous positive airway pressure - constant airflow
CPAP
Auto titrating positive airway pressure - algorithmic control
APAP
Intermittent and reversible airflow obstruction. Affects airways only, not alveoli. Inflammation and bronchconstriction.
asthma
What triggers asthma symptoms?
allergens, cold air, dry air, airborne particles, ASA/NSAIDs, exercise, and food w/ MSG
Asthma symptoms
-audible wheeze, increased respiratory rate, SOB
-Increased cough
-Use of accessory muscles
-Barrel chest
-Long breathing cycle
-Cyanosis
-Hypoxemia
-CO2 retention
-Increased mucus
Emergent, life threatening situation for pts with asthma. Symptoms do not respond to usual treatment in 30 minutes.
Status asthmaticus
Asthma risk factors
genetic, environmental
Labs for asthma
ABG’s- low PAO2, low PACO2 initially, & increased PACO2 later in attack
Diagnostics for asthma
Pulmonary function tests (PFTs)
Forced vital capacity (FVC)
Forced expiratory volume in first second (FEV1)
Peak expiratory flow rate (PEFR)
Asthma meds
Bronchodilators: Short-Acting Beta2 Agonists (SABA) & Long-Acting Beta2 Agonists (LABA), Cholinergic Antagonists, Anti-inflammatories, Corticosteroids, Cromone, and Leukotriene Modifier
Cause bronchodilation through relaxing bronchiolar smooth muscle by binding to and activating pulmonary beta2 receptors
bronchodilators- SABA and LABA
Bronchodilator that primary use is a fast-acting reliever (RESCUE) drug to be used either during an asthma attack or just before engaging in activity that triggers an attack
Short-Acting Beta2 Agonist (SABA)
Ex: albuterol and levalbuterol
Albuterol pt teaching
Carry drug with them at all times because it can stop or reduce life-threatening bronchoconstriction
Levalbuterol pt teaching
-Monitor heart rate because excessive use causes tachycardia
-Teach pt technique for using the MDI or DPI
Bronchodilator that causes bronchodilation through relaxing bronchiolar smooth muscle by binding to and activating pulmonary beta2 receptors. Onset of action is slow with long duration. Primary use is PREVENTION of an asthma attack.
Long-Acting Beta2 Agonist (LABA)
Ex: Salmeterol
Salmeterol pt teaching
Do not use as a reliever drug
Spacers are helpful for what pts?
children, confused, elderly, and disabled pts
Causes bronchodilation by inhibiting the parasympathetic nervous system, allowing the sympathetic system to dominate, releasing norepinephrine that activates beta2 receptors. The purpose is to both relieve & prevent asthma and improve gas exchange.
Cholinergic Antagonists
Ex: ipratropium and tiotropium
Tiotropium pt teaching
Increase daily fluid intake because the drugs cause mouth dryness
Disrupt production pathways of inflammatory mediators. The main purpose is to prevent an asthma attack caused by inflammation or allergies (controller drug).
Corticosteroids
Ex: Fluticasone, Beclomethasone, Budesonide, and Prednisone
Fluticasone, Beclomethasone, & Budesonide (MDI inhaled drug) pt teaching
Drug daily even when no symptoms are present, good oral care & check for lesions
Prednisone pt teaching
Increases risk of infection, do not suddenly stop the drug for any reason
Blocks the leukotriene receptor, preventing the inflammatory mediator from stimulating inflammation. Purpose is to prevent asthma attack triggered by inflammation or allergens.
Leukotriene Modifier
MDI
Metered dose inhaler
DPI
Dry powder inhaler
Management of asthma - step wise method used for prescribing
ASTHMA
Adrenergics (Beta2 Agonists)
Steroids
Theophylline
Hydration (IV)
Mask O2
Anticolinergics
Ace inhibitors can cause
angioedema
Also called atopic allergy, hay fever, most common type
1st exposure –> T lymphocytes tell B lymphocytes to create IgE specific to allergen –> Mast cells (tissue) basophils (blood stream) have IgE receptors with lots of IgE attached —> allergen binds to IgE –> causes degranulation (allergic cascade)
Patho of allergies
Allergies Type I
Hay fever, allergic asthma, anaphylaxis, angioedema
What causes allergies?
Excessive production of immunoglobulin E (IgE) antibody class
Allergens are contracted by
inhalation, ingestion, or injection
Symptoms of allergies
Sneezing, runny nose, & red, watery, itchy eyes
Can be seasonal
Are allergies genetic?
yes
Allergy labs
ABG’s
Allergy diagnostics
Skin prick test (SPT), Intradermal skin test, Blood tests, Physician supervised challenge tests, Patch tests
Allergy Meds
- Supportive therapy – no nasal washing!
- Complementary and alternative therapy - vitamin C, zinc
- Steroids - Used for anti-inflammatory effect and act to decrease edema in the bronchial airways and decrease mucus secretion.
- leukotriene inhibitors – Montelukast (Singulair)
- Antihistamines – Diphenhydramine (Benadryl)
- Eye decongestants
- Decongestants – Avoid use of nasal decongestant sprays regularly because they can cause a rebound effect.
- Bronchodilators
- Anti-inflammatories
- Antipyretics
- Mast cell stabilizers
Allergy procedures
Immunotherapy- Allergy Shots: Subcutaneous injection of low amount of allergens, then gradual increased amount.
Allergy complications
Angioedema & Anaphylaxis can be fatal - Potential for airway obstruction as a result of mucosal swelling & anxiety as a result of cerebral hypoxia and threat of death.
Uticaria (hives)
What causes Tuberculosis/TB?
Mycobacterium tuberculosis - Airborne droplets inhaled
Is TB contagious?
Only with symptoms
TB Risk Factors
- Frequent contact with untreated person
- Immunocompromised
- Living in crowded areas
- Older homeless adults
- IVDU or ETOH abusers
- Lower socioeconomic status
- Foreign immigrants
TB disease course and findings (sx)
Most common bacterial infection worldwide
Airborne, May be infected with bacillus, but not have active TB, slow onset
* Persistent cough, mucopurulent sputum, blood streaks (hemoptysis)
* Progressive fatigue, lethargy
* Nausea, anorexia, and/or unintended weight loss
* Irregular menses
* Low-grade fever, night sweats, chills
Symptom screening - at this time, do you have any of these symptoms?
1. Coughing for more than 2-3 weeks?
2. Coughing up blood?
3. Weight loss of more than 10 pounds for no known reason?
4. Fever of 100 degrees Fahrenheit for over 2 weeks?
5. Unusual of heavy sweating at night?
6. Unusual weakness or extreme fatigue?
Standard screening questions for TB
TB Labs & Diagnostics
-NAA test - secretions
-Sputum culture
-BCG vaccine & chest Xray - think about Yule
-Tuberculin (Mantoux) test - skin test
-Blood analysis - QuantiFERON-TB Gold (what I had for the program)
TB Meds
Combination drug therapy w/ strict adherence!
Isoniazid- kills actively growing mycobacteria & inhibits growth
Take on empty stomach, avoid alcohol, liver toxicity
Rifampin- kills slower growing organisms
Orange-reddish staining of skin, urine, and other secretions. Contact lenses will become permanently stained. Reduces effectiveness of oral contraceptives.
Pyrazinamide- can effectively kill organisms residing within very acidic environment
Makes gout worse, photosensitivity, and increases risk of sunburn
Ethambutol- inhibits bacterial RNA synthesis, thus suppressing bacterial growth
Can cause optic neuritis
Nursing Care for TB pts
-Promote airway clearance by increasing fluids, using incentive spirometer, TCBD
-Decrease drug resistance and infection spread
-Airborne precautions in hospital
-No airborne precautions at home; but family should be tested
-Drug compliance is very important
-Improve nutrition
-Manage fatigue and anxiety
COPD is the name we use for a person w/
emphysema and bronchitis
Chronic inflammation of the bronchi & bronchioles
chronic bronchitis
Decreased lung elasticity and hyperinflation of the lung
emphysema
What causes COPD?
smoking
COPD Risk factors
-genetic/environmental
-smoking
-asthma (12x risk for COPD)
-AAT deficiency (gene is recessive)
Sx of COPD
-easily fatigued
-frequent respiratory infections
-use of accessory muscles
-orthopneic
-thin in appearance
-Cor Pulmonale (R sided heart failure)
-wheezing
-pursed lip breathing
-chronic cough
-barrel chest
-dyspnea
-prolonged expiratory time
-clubbing
COPD Labs
-ABGs
-sputum samples
-CBC
- hemoglobin and hematocrit
-serum electrolytes
-serum AAT (rule out genetic disorder)
COPD Diagnostics
PFTs
Chest X-ray
COPD Meds
Same as asthma
-beta adrenergic agents
-cholinergic antagonists
-methylxanthines
-corticosteroids
-NSAIDs
-mucolytics
COPD Procedures
-lung reduction surgery
-lung transplant surgery (rare)
COPD complications
hypoxemia and acidosis
Nicotine replacement options to help with smoking cessation
skin patches, gum, lozenges, inhaler, nasal spray, varenicline (Chantix), and bupropion
Varenicline (Chantix) will decrease cravings. Should be taken with a full glass of water. Side effects include
hallucinations, manic behavior, impaired judgement, nausea, and abnormal dreams
Patient & Family Education- Smoking Cessation
-Make a list of the reasons why you want to stop smoking
-Set a date and keep it
-Ask for help
-Consult your health care provider about nicotine replacement therapy
-Remove ashtrays and lighters
-Reward yourself w/ money you save from not smoking
-Avoid places that might tempt you to smoke
-Find activities that keep your hands busy
-Take five deep breaths when you feel the urge to smoke
-Keep plenty of healthy, low-calorie snacks
-Drink at least 8 glasses of water each day
-Begin an exercise program
-Don’t beat yourself up for backsliding
-Think of each day w/o tobacco as a major accomplishment
Diaphragmatic or Abdominal Breathing
-Lie on your back w/ knees bent. If you can not lie comfortably, sit in a chair.
-Place your hands or book on your abdomen to create resistance
-Begin breathing from your abdomen while keeping chest still.
Pursed Lip Breathing
-Close your mouth and breathe in through your nose
-Purse your lips as you would to whistle. Breathe out slowly through your mouth w/o puffing your cheeks. Spend at least twice the amount of time it took to breath in.
-Use abdominal muscles to squeeze every bit of air out you can
What is a vibratory positive expiratory pressure device used for in COPD pts?
It is used to help pts remove airway secretions.
