exam 2 Flashcards
cholecystitis
inflammation of the gallbladder, calculous cholecystitis
pain, tenderness, rigidity of the Rt upper abdomen, N/V
cholelithiasis
calculi or gallstones risk factors: 5 Fs female fat forty years old fluctuation in weight fertile (estrogen)
clinical manifestations:
Biliary colic (sharp pain)
Episodic, vague, right upper abdomen. May radiate to back, right scapula and shoulder
Severe, steady
Begins suddenly after a meal (high-fat)- may last 5 hours
Accompanied by N/V, dyspepsia, eructation, flatulence, feeling of fullness
assessment/diagnostic findings:
Ultrasonography of RUQ - study of choice, accurate
Endoscopic Retrograde- looks at liver, bile, pancreatic duct, NPO, Sedation - ride home
Cholangiopancreatography (ERCP)- know this
prevention:
medical management:
Asymptomatic:
Nutritional and supportive therapy
Pharmacologic therapy- 6-12 months to dissolve stones
With symptoms:
Nonsurgical removal of gallstones- Extracorporeal shock wave lithotripsy
Surgical management- open or laparoscopic cholecystectomy
Gerontologic consideration-high mortality rate
Nursing Management:
Nutritional Modification - low fat diet
During acute pain episode: Low fat liquids
Advance as tolerated:
cooked fruits, rice, lean meats, mashed potatoes, non-gas forming veggies, bread, coffee with low-fat milk or tea (not black tea)
Avoid:
eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming veggies, alcohol & refined, fatty, and fried foods (can cause episodes)
risk factors:
Cystic fibrosis
Diabetes
Frequent changes in weight
Ileal resection or disease
Low-dose estrogen therapy—carries a small increase in the risk of gallstones
Obesity
Rapid weight loss (leads to rapid development of gallstones and high risk of symptomatic disease)
Treatment with high-dose estrogen (e.g., in prostate cancer)
Women, especially those who have had multiple pregnancies or who are of Native American or U.S. southwestern Hispanic ethnicity
Laparoscopic Cholecystectomy
Nursing Process-
Assessment: focus on the patient’s respiratory status
a history of smoking, previous respiratory problems, shallow respirations, a persistent or ineffective cough, and the presence of adventitious breath sounds
Nutritional status
previously obtained laboratory results to obtain information about the patient’s nutritional status.
Nursing Diagnosis: Acute pain Impaired gas exchange Skin integrity & drainage Risk for infection Imbalanced nutrition
Planning and Goals:
relief of pain, adequate ventilation, intact skin and improved biliary drainage, optimal nutritional intake, absence of complications, and understanding of self-care routines.
Nursing Interventions: low-fowlers position IV fluids and NG suction soft diet after bowel sounds return Patient Education: Managing Pain: Sitting upright or use a heating pad Take analgesic meds as needed Resuming Activity: Begin walking immediately Take shower or bath 1 to 2 days after Drive car 3-4 days after Avoid lifting heavy objects Resume sexual activity when desired Caring for the Wound Check for infection Wash puncture site with mild soap and water Allow special adhesive strips to puncture site to fall off Resume normal diet Managing follow-up care
Complications: bleeding & GI symptoms Obstruction of the bile duct: Ischemia Gangrene Rupture of the gallbladder wall- abscess or peritonitis (rigid, board-like abdomen, guarding) Bile peritonitis Postcholecystectomy syndrome
Acute Pancreatitis
clinical manifestations: -Abdominal pain! Severe (“knife-like”), unrelenting, Sudden onset Mid-epigastric area or LUQ May occur 24-48 hrs. after heavy meal or alcohol ingestion May be diffuse or radiate to back, left flank, left shoulder Acutely ill. Guarding. May be relieved by fetal position, sitting up & leaning forward Persists for days to weeks -Postural hypotension -Tachycardia -N/V -Abd. distention, rigidity -Absent or decreased bowel sounds -Fever -Mild to generalized jaundice -Retroperitoneal bleeding \+ Cullen’s sign: bruising on abd \+ Turner’s sign: bruising on flank area
risk factors: Gallstone Ethanol (alcohol) Trauma Steroids Mumps Autoimmune Scorpion bite Hyperlipidemia Ercp Drugs
assessment:
SAMPLE
Signs and Symptoms, Allergies, Medications, Past medical history, Last oral intake, Event prior
OPQRST
Onset, Provocation/Palliation/Position, Quality, Region/Radiation, Severity, Time
Labs:
Serum amylase & lipase (within 2-12 hrs.)
Urine amylase
Serum glucose, potassium, magnesium, & calcium
Serum bilirubin
Liver enzymes: AST, ALP
WBC
Hemoglobin & hematocrit
(hemorrhagic pancreatitis)
Nursing Diagnosis:
Acute Pain: Sit and lean forward
Fluid/electrolyte disturbances: Give IV fluids
Imbalanced Nutrition: They can’t eat because of pain. Keep patient NPO first, then help with nutrition. Diet high in protein and low in fat. Avoid heavy meals and alcohol.
prevention:
medical management:
NPO
NG feedings ok; start early.
TPN
Acute pain management: IV
Narcotics: morphine, fentanyl, hydromorphone (Dilaudid)
Chronic pain control:
NSAIDs (Toradol)
Avoid narcotics to prevent dependence
Antibiotics if infection is present
Pancreatic enzymes:
Pancrelipase (Lipancreatin)
Exogenous source of protease, amylase & lipase
For acute & chronic pancreatitis & pancreatic cancer
Enhances digestion of starches, fats
Promotes nutrition & decrease number of BMs
Do not chew capsule contents.
Wipe lips (to prevent skin breakdown or irritation).
complications: Fluid and Electrolytes Disturbances: CV Renal- acute renal failure Hypovolemic shock- Up to 6 L of fluid can be third‑spaced; caused by retroperitoneal loss of protein‑rich fluid from proteolytic digestion Pancreatic Necrosis an inflammatory mass that may be infected. May lead to multiple organ failure, shock. Most common cause of death
gerontologic considerations that influence acute pancreatitis
Mortality rate increases with aging
The incidence of multiple organ dysfunction syndrome (MODS) increases r/t progressive decrease in physiologic function of major organs with increasing age.
Close monitoring of major organ function and aggressive treatment of necessary to reduce mortality.
Chronic Pancreatitis
Manifestations:
Pain:
Recurrent episodes of severe, deep, epigastric and LUQ abdomen, may radiate to back.
Burning, gnawing, nagging, constant pain with periods of acute exacerbation
Accompanied by vomiting, may last for days to weeks
As disease progresses, interval between episodes of pain becomes shorter
GI/GU:
Weight loss, anorexia, N/V, malnutrition and muscle wasting, steatorrhea, flatulence, constipation
Jaundice and dark urine.
Risk Factors:
Alcohol and Malnutrition
DIagnostic findings: ERCP: Provides details about the anatomy of the pancreas and the pancreatic and biliary ducts. It is also helpful in obtaining tissue. CT, MRI Glucose tolerance test Increase serum amylase, serum lipase
Medical Management:
Nonsurgical: pain control, do not want to use narcotics.
Surgical: not often
Gerontologic consideration
Compare and contrast Acute vs Chronic pancreatitis
• Acute Pancreatitis: o Abrupt onset o Often reversible after treatment o May lead to chronic pancreatitis o Acute necrotizing pancreatitis is a life threatening condition • Chronic Pancreatitis: o Continuing inflammatory disease o Irreversible pathology o Relapsing acute pancreatitis o Exocrine pancreatic insufficiency can result o Diabetes mellitus can result o Triaditis can result in cats
cancer of pancreas
Risk Factors: Cigarette smokers (2-3 times more) Obesity Chemical and toxin exposure (petrolem) Diabetes mellitus Chronic pancreatitis African Americans > Caucasians Male greater than female Incidence increases over 45 years old Diet that is high-fat and low in fruits, vegetables Inherited genetic syndromes
Manifestations: S/S APPEAR WHEN DISEASE IS FAR ADVANCED Upper abd. pain. May radiate to middle, upper back Jaundice, icterus Anorexia, unintentional wt. loss Ascites S/S of insulin insufficiency (glycosuria, hyperglycemia) Itching N/V Palpable abd. mass
Assessment & Diagnostic Findings:
Spiral CT (85-90% accurate)
MRI
ERCP
Medical Management: Pancreatoduodenectomy (Whipple procedure or resection)- Treatment options: Surgery Radiation Chemotherapy Pancreatoduodenectomy: Involves: Removal of gallbladder Removal of head of the pancreas Removal of distal 1/3 of stomach + portion of jejunum Removal of duodenum Removal of lower ½ of the common bile duct Reconstruction: Anastomosis of remaining pancreas & stomach to jejunum
Nursing Management: Relieving pain- FIRST Improving breathing pattern Monitor for shock, hemorrhage, hepatorenal failure Manage NG, suction Multiple IV and arterial lines used for fluid & blood replacement, hemodynamic monitoring Nutrition Risk for bleeding Focus on psychological, emotional state
After pancreatic surgery:
Lots of tubes!
Airway is priority and then pain
Slow down dumping syndrome
Do not sit upright after eating - Lower head of bed
Slow down amount of time food moves to stomach , so they can digest better
Sit up to eat and then lower HOB, 45 degrees
No liquids when eating meal – fluid can move food faster
Monitor & manage pt in ICU:
VS, ABGs, oxygenation, lab values, urine output
multiple IV & arterial lines; hemodynamic monitoring
manage mechanical ventilation
Provide comfort. Manage pain.
Promote nutrition. Address malabsorption and diabetes.
Provide psychological & emotional support.
Educate about self-care.
Diet modifications
Meds: analgesics, TPN, pancreatic enzyme replacement
Wound & skin care
Management of drains, stents
Obesity
Clinical manifestations:
Causes: Behavioral Environmental Physiologic Genetic
Associated Disorders: Cancer Type 2 diabetes by tenfold HTN by fourfold Alzheimer's
Secondary Causes: Diseases/disorders- Hypothyroidism Cushing syndrome Medications Weight Gain Medications- Beta blockers: metoprolol Calcium channel blockers: amlodipine Antipsychotics: chlorpromazine; clozapine; olanzapine Antidiabetics: insulins; sulfonylureas Hormones: corticosteroids; medroxyprogesterone Weight Loss AEDs: lamotrigine (Lamictal); topiramate (Topamax) Antidepressants: bupropion (Wellbutrin, Zyban); Antidiabetics: metformin (Glucophage)
Assessment and diagnostic findings:
-Calculate body mass index (BMI): Person’s weight in KG divided by the square of height in meters) May need to convert lbs to kgs and inches to meters.
oBMI classifications:
Below 18.5: Underweight
18.5-24.9: Normal or healthy weight
25.0-29.9: Overweight
30-34.9: Class 1 obesity
35-39.9: Class ll Obesity
Above 40: Class lll obesity (Extreme, severe)
oDiagnostic lab studies:
CV disease: cholesterol and triglycerides
Type 2 diabetes: fasting blood glucose and glycosylated hemoglobin.
Nonalcoholic fatty liver disease: aspartate aminotransferase and alanine aminotransferase.
Medical management:
oLifestyle modification:
Set weight loss goals
Increase physical activity
Improve diet habits: Commercial diets do not work.
Track: Daily food intake and Nutritional value and caloric content
Healthy Diet Components:
Few processed foods, sugars, and trans fats, and heavy in plant-based foods.
Promote healthy sleep habits
Address barriers to change
Self-monitoring and strategizing ongoing lifestyle changes aime at a healthy weight
Healthy eating strategies:
Limit or eliminate: Processed foods, High caloric beverages, Fast foods, Vending machine foods, and Foods high in sugars
Encourage: Reduce portions; use smaller plates and measure foods, Schedule and plan meals and snacks, Eat at home more than out, Eat breakfast, Limit snacks, Eat nutritious foods, Drink water, and Stay within daily caloric intake plan.
Pharmacologic management:
Medications are used if we cannot help with the weight through exercise and diet.
Antiobesity meds are meant to supplement not supplant/replace diet modifications and exercise.
Need to encourage the use of multivitamins with these. If they are taking other meds they need to let the doctor know.
Indications for antiobesity meds:
BMI> 30
BMI> 27 with related concomitant morbidities
Orlistat:
Prevents digestion of fats.
AE’s: Oily discharge, reduced food and vitamin absorption, and decreased bile flow.
Lorcaserin:
Simulates serotonin receptors in the hypothalamus in the brain to curb appetite.
AE’s: HA, dry mouth, fatigue, and nausea
Phentermine/topiramate-ER:
Suppresses the appetite and induces a feeling of satiety
AE: Dry mouth, constipation, nausea, change in taste, dizziness, insomnia, and numbness and tingling of extremities.
Contraindications: hyperthyroidism, glaucoma, MAO inhibitor.
Nonsurgical or surgical interventions:
Minimally-invasive interventions:
Vagal blocking:
Placement of a pacemaker-like device into the SQ tissue in the lateral thoracic cavity.
Blocks vagus nerve via implanted device
Few SE/AE’s
Pt should be educated to recharge the device twice weekly.
Intragastric balloon therapy:
Endoscopic placement of saline-filled balloons into the stomach.
Remains in place for 3-6 months
SE/AE’s: N/V, balloon rupture causing obstruction
oSurgical Management:
Bariatric Surgery
Performed after nonsurgical methods have failed.
Selection Criteria:
BMI of 30 for patients with comorbid conditions
Need counseling before and after: lifestyle
Results: 10-35% body weight within 2-3 years.
Improved comorbidities: DM, HTN, OSA, dyslipidemia
Types:
Roux-en-Y gastric bypass (RYGB)
Gastric Banding
Sleeve gastrectomy
Biliopancreatic diversion with duodenal switch
Nursing Management:
Mechanics of ventilation and circulation
Heart failure and HTN are common
Maintain in low Fowler position
Continuous pulse oximetry- every shift at minimum.
Supplemental oxygen and CPAP
Central and peripheral circulatory compromise
Heart failure and HTN are common
Use appropriate size BP cuff
Monitor for venous thromboembolism (VTE) which places at risk for DVT and PE
Skin Integrity & Body Mechanics
Increased adipose tissue diminishes supply of blood, oxygen & nutrients to peripheral tissues
The presence of more folds in the skin is associated with more skin moisture and increased friction. Immobility. - pressure ulcer risk.
Use specialty bariatric equipment (lifts, transport equipment, commodes)
Turn every 2 hours- prevent pressure ulcers
Implement safe patient handling protocols so nurse does not incur musculoskeletal injury.
Nursing Process for Bariatric Surgery
Performed only after nonsurgical methods have failed
Selection by multidisciplinary team
Criteria has changed to include BMI of 30 for patients with comorbid conditions
Need counseling before & after re: lifestyle
Typical results: 10-35% of body wt. within 2-3 years
Improved comorbidities (DM, HTN, OSA, dyslipidemia)
Assessment: Preoperative Care: Education and counseling: Surgical risks and benefits Complications Postsurgical outcomes Dietary changes Lifelong follow-up Lab testing Postoperative care: Monitor for leak of anastomosis Assess to ensure goals for recovery are met Assess for absence of complications General assessment
Nursing Diagnoses:
Pain r/t incision/surgery
Planning and Goals:
Nursing management:
Ensuring dietary restrictions: Clear liquid diet 24-48 hours before surgery
Reducing anxiety
Relieving pain
Ensuring fluid volume balance: Iv
Preventing infection
Ensuring adequate nutritional status: After bowel sounds return, six small feedings, 600-800 calories per day. Fluids between meals to prevent dehydration.
Supporting body image changes
Ensuring maintenance of bowel habit
Monitoring and managing potential complications
Collaborative problems and potential complications:
Hemorrhage
Venous thromboembolism
Bile reflux
Dumping Syndrome: Dump the food out of the stomach
Food moving out of the GI too fast. This will cause them to not have enough time to absorb the nutrition. The GI cannot function.
Decreasing the risk:
Do not drink and eat at the same time.
Lower the HOB, not sitting up to eat. Slow down the movement of the food so they can absorb it.
Dysphagia
Bowel or gastric outlet obstruction
Dietary Guidelines:
Eat smaller and more frequent meals containing protein and fiber. Meal should not exceed 1 cup.
High nutrient foods
Consume fat as tolerated
Low carbohydrate intake
Eat two protein snacks daily
Eat slow and chew
Assume a low Fowler position during mealtime and remain there for 20-30 minutes- decreases likelihood of dumping syndrome.
Do not drink fluid with meals
Do drink plenty of water, avoid liquid calories (alcohol, fruit drinks, nondiet sodas
Take dietary supplements of vitamins and medium-chain triglycerides
Follow up monthly injections of vitamin B12 and iron
Walk for 30 min a day.
Neurological assessment
Consciousness and cognition: mental status (Includes multiple functions, each must be assessed and adds to the clinical picture), GCS (glascow coma scale), intellectual function (abilities like counting/math, critical thinking/problem solving, reasoning), thought content, emotional status (affect), language ability (types of aphasia result from injury to different parts of the brain), impact on lifestyle Level of Consciousness—alert, lethargic, stupor, coma GCS: Eye Opening: Spontaneous 4 To sound 3 Pain/pressure 2 None 1 Verbal Response: Oriented 5 Disoriented/Confused 4 Inappropriate words 3 Incomprehensible sounds 2 No response 1 Motor Response: Obeys verbal commands 6 Purposeful/localizes 5 Withdraws to pain 4 Flexion 3 Extension 2 No response 1
Cranial nerves
Motor system: muscle size, muscle tone and strength, coordination and balance, Romberg test
strength: 5 indicates full power of contraction against gravity and resistance or normal muscle strength; 4 indicates fair but not full strength against gravity and a moderate amount of resistance or slight weakness; 3 indicates just sufficient strength to overcome the force of gravity or moderate weakness; 2 indicates the ability to move but not to overcome the force of gravity or severe weakness; 1 indicates minimal contractile power (weak muscle contraction can be palpated but no movement is noted) or very severe weakness; and 0 indicates no movement
Sensory system: tactile sensation, superficial pain, temperature, vibration and position sense (proprioception)
Reflexes: DTRs, biceps, triceps, brachioradialis, patellar Achilles, superficial, pathologic, plantar (Babinski)
Gerontologic considerations: It is important not to attribute abnormality or dysfunction to aging without appropriate investigation. Although mental processing time decreases with age, memory, language, and judgment capacities remain intact.
Nursing interventions for patients having EEG, CT, or MRI
EEG:
To increase the chances of recording seizure activity, it is sometimes recommended that the patient be deprived of sleep the night before the EEG. Anticonvulsant agents, tranquilizers, stimulants, and depressants should be withheld 24 to 48 hours before an EEG, because these medications can alter the EEG wave patterns or mask the abnormal wave patterns of seizure disorders. Coffee, tea, chocolate, and cola drinks are omitted from the meal before the test because of their stimulating effect. However, the meal itself is not omitted, because an altered blood glucose level can cause changes in brain wave patterns. The patient is informed that the standard EEG takes 45 to 60 minutes; a sleep EEG requires 12 hours. The patient is assured that the procedure does not cause an electric shock and that the EEG is a diagnostic test, not a form of treatment. An EEG requires the patient to lie quietly during the test. Sedation is not advisable, because it may lower the seizure threshold in patients with a seizure disorder and it alters brain wave activity in all patients. The nurse needs to check the prescription regarding the administration of anticonvulsant medication prior to testing. Routine EEGs use a water-soluble lubricant for electrode contact, which can be wiped off and removed by shampooing later. Sleep EEGs involve the use of collodion glue for electrode contact, which requires acetone for removal.
CT:
preparation for the procedure and patient monitoring
educating the patient about the need to lie quietly throughout the procedure.
Ongoing patient monitoring during sedation is necessary.
If a contrast agent is used, assessed before for an iodine/shellfish allergy, because the contrast agent used may be iodine based. Kidney function must also be evaluated because the contrast material is cleared through the kidneys. A suitable IV line for contrast injection and a period of fasting (usually 4 hours) are required prior to the study. Patients who receive an IV contrast agent are monitored during and after the procedure for allergic reactions and changes in kidney function. Fluid intake is also encouraged after IV contrast to facilitate contrast clearance through the kidney.
MRI:
providing education
obtaining an adequate history-Ferromagnetic substances in the body may become dislodged by the magnet, so history of working with metal fragments must be reviewed. The patient is questioned about any implants of any metal objects (e.g., aneurysm clips, orthopedic hardware, pacemakers, artificial heart valves, intrauterine devices). These objects could malfunction, be dislodged, or heat up as they absorb energy. Cochlear implants will be inactivated by MRI; therefore, other imaging procedures are considered. A complete list of metal compatibility may be found on MRI manufacturer Web sites. Before the patient enters the room where the MRI is to be performed, all metal objects and credit cards (the magnetic field can erase them) must be removed. This includes medication patches that have a metal backing and metallic lead wires; these can cause burns if not removed (Fischbach & Dunning, 2015). No metal objects may be brought into the room where the MRI is located; this includes oxygen tanks, IV poles, ventilators, or even stethoscopes. The magnetic field generated by the unit is so strong that any metal-containing items will be strongly attracted and literally can be pulled away with such force that they fly like projectiles toward the magnet. There is a risk of severe injury and death. Further, damage to expensive equipment may occur.
Altered level of consciousness
Level of responsiveness and consciousness is the most important indicator of the patient’s condition
LOC is a continuum from normal alertness and full cognition (consciousness) to coma (Table 66-1)
Altered LOC is not the disorder but the result of a pathology
Coma: unconsciousness, unarousable unresponsiveness
Akinetic mutism: unresponsiveness to the environment, makes no movement or sound but sometimes opens eyes
Persistent vegetative state: devoid of cognitive function but has sleep–wake cycles
Locked-in syndrome: inability to move or respond except for eye movements due to a lesion affecting the pons
Assessment:
Level of responsiveness or consciousness
Eye opening; verbal and motor responses; pupils (size, equality, reaction to light)
Pattern of respiration
Respiratory pattern
Cheyne–Stokes respiration
Hyperventilation
Ataxic respiration with irregularity in depth/rate
Eyes
Pupils (size, equality, reaction to light)
Equal, normally reactive pupils
Equal or unequal diameter
Progressive dilation
Fixed dilated pupils
Eye movements
Normally, eyes should move from side to side
Corneal reflex
When cornea is touched with a wisp of clean cotton, blink response is normal
Facial symmetry
Asymmetry (sagging, decrease in wrinkles)
Swallowing reflex
Drooling vs. spontaneous swallowing
Absent in coma
Neck
Stiff neck
Absence of spontaneous neck movement
Response of extremity to noxious stimuli
Firm pressure on a joint of the upper and lower extremity
Observe spontaneous movements
Deep tendon reflexes
Tap patellar and biceps tendons
Pathologic reflexes
Firm pressure with blunt object on sole of foot, moving along lateral margin and crossing to the ball of foot
Abnormal posture
Observation for posturing (spontaneous or in response to noxious stimuli)
Flaccidity with absence of motor response
Decorticate posture (flexion and internal rotation of forearms and hands)
Decerebrate posture (extension and external rotation)
Goals may include: Maintenance of clear airway Protection from injury Attainment of fluid volume balance Maintenance of skin integrity Absence of corneal irritation Effective thermoregulation Accurate perception of environmental stimuli Maintenance of intact family or support system Absence of complications
Priorities: Safety ABC- airway, breathing, circulation Time and effect- something i can do right now without orders and equipment Example- sit patient up who cant breath
Preventing additional injuries, imbalances
Potential complications: Respiratory distress or failure Pneumonia Aspiration Pressure ulcer Venous thromboembolism (VTE) Contractures
Seizures
Abnormal episodes of motor, sensory, autonomic, or psychic activity (or a combination of these) resulting from a sudden, abnormal, uncontrolled electrical discharge from cerebral neurons
Classification of seizures
Focal: originates in one hemisphere
Generalized: occur and engage bilaterally
Unknown: epilepsy spasms
“Provoked” related to acute, reversible condition
Causes: Cerebrovascular disease, Hypoxemia, Fever (childhood), Head injury, Hypertension, Central nervous system infections, Metabolic and toxic conditions, Brain tumor, Drug and alcohol withdrawal, Allergies
Triggers:
Specific time of day or night
Sleep deprivation – overtired, not sleeping well, not getting enough sleep
At times of fevers or other illnesses
Flashing bright lights or patterns
Alcohol or drug use, Use of certain medications
Stress
Associated with menstrual cycle (women) or other hormonal changes
Not eating well, low blood sugar, certain foods
Epilepsies-a group of syndromes characterized by unprovoked, recurring seizures
Classified by specific patterns of clinical features
Age at onset
Family history
Seizure type
Can be primary or secondary
Women:
Increased frequency during menses r/t hormone changes
Effectiveness of contraceptives can be decreased by the use of anticonvulsants
May note a change in pattern of seizure activity during pregnancy, require special care-risk of congenital fetal anomaly is 2-3x higher in women with epilepsy r/t maternal seizures, anticonvulsant medications, and genetic predispositions
Bone loss associated with long term use of some anticonvulsant medications; patient’s should be screened and educated about risks and prevention of osteoporosis
Gerontologic:
High incidence of new onset epilepsy
Cerebrovascular disease is leading cause of seizures of older adults, also increased incidence associated with head injury, dementia, infection, alcoholism, and aging.
Medication absorption, distribution, metabolism, and excretion altered r/t age related changes in liver and renal function. Older adult patients need to be monitored closely for adverse effects, toxicity, and osteoporosis. Cost can be a concern for adherence.
Education:
Take anticonvulsant medications daily as prescribed to keep the drug level constant to prevent seizures. Never discontinue medications, even if there is no seizure activity.
Keep a medication and seizure record (in electronic or paper format), noting when medications are taken and any seizure activity.
Notify the primary provider if unable to take medications due to illness.
Have anticonvulsant medication serum levels checked regularly. When testing is prescribed, report to the laboratory for blood sampling before taking morning medication.
Avoid activities that require alertness and coordination (driving, operating machinery) until after the effects of the medication have been evaluated.
Report signs of toxicity so that dosage can be adjusted. Common signs include drowsiness, lethargy, dizziness, difficulty walking, hyperactivity, confusion, inappropriate sleep, and visual disturbances.
Avoid over-the-counter medications unless approved by the primary provider.
Carry a medical alert bracelet or identification card specifying the name of the anticonvulsant medication and primary provider.
Avoid seizure triggers, such as alcoholic beverages, electrical shocks, stress, caffeine, constipation, fever, hyperventilation, and hypoglycemia.
Take showers rather than tub baths to avoid drowning if seizure occurs; never swim alone.
Exercise in moderation in a temperature-controlled environment to avoid excessive heat.
Develop regular sleep patterns to minimize fatigue and insomnia.
Be aware of and use the Epilepsy Foundation of America (EFA) special services, including help in obtaining medications, vocational rehabilitation, and coping with epilepsy.
Status Epilepticus (acute prolonged seizure activity)
A series of generalized seizures that occur without full recovery of consciousness between attacks
Continuous clinical or electrical seizures lasting at least 30 minutes
Considered a medical emergency
Produces cumulative effects
Vigorous muscle contractions produce heavy metabolic demand
Interference with respirations-venous congestion and hypoxia of the brain
Worry about o2 brain injury if over 5 mins
Stay with patient- call for help
Administer meds within 1-2 minutes if possible!
During a Seizure:
Monitor seizure qualities
Circumstances prior (try to identify a trigger)
Occurrence of an aura
First thing that a patient does with the onset of a seizure (stiffness or gaze, etc)
Movements/presentation of the seizure
Incontinence
Duration
Presentation at end of seizure-cognitive status?
Provide privacy, and protect the patient from curious onlookers.
Ease the patient to the floor, if possible.
Protect the head with a pad to prevent injury (from striking a hard surface).
Loosen constrictive clothing and remove eyeglasses.
Push aside any furniture that may injure the patient during the seizure.
If the patient is in bed, remove pillows and raise side rails.
Do not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything in the mouth during a seizure. Broken teeth and injury to the lips and tongue may result from such an action.
Do not attempt to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury.
***If possible, place the patient on one side, which allows the tongue to fall forward and facilitates drainage of saliva and mucus but do not restrain the patient to do so, usually done when seizure is over, maintaining safety/prevention or injury is highest priority during the seizure. If suction is available, use it if necessary to clear secretions (outside the mouth to suction away expelled or ozzing secretions, never insert anything into the mouth during a seizure). After the seizure, may suction out the mouth.
After a seizure:
May be posticatal- maintain privacy, safety,
Assessment- hypoxia, vomiting, post-seizure neuro status and post ictal qualities
Make sure airway is patent
Move patient to a side-lying position to facilitate drainage of oral secretions, prevent aspiration
Bed low locked position with 3 rails up-maybe altered mental status or another seizure.
Headache
Types:
Sinus- pain is behind forehead/checkbones
cluster- pain is in and around one eye
time, and may have a crescendo-decrescendo patturn
May be accompanied by eye watering and nasal congestion
Described as “penetrating”
tension- pain is like a band squeezing head
migraine- pain, nausea & visual changes
Premonitory:
80% of patients
Symptoms hours or days prior
Depression, irritability, cold, food cravings, anorexia, change in activity level, increased urination, diarrhea, or constipation.
Aura:
Focal neurological symptoms, vary per patient, at the onset and/or during the headache phase
May include light flashes or bight spots, numbness or tingling, mild confusion, slight weakness of an extremity, drowsiness, or dizziness.
Headache:
Severe and incapacitating headache
Often associated with photophobia, phonophobia, allodynia, or nausea and vomiting.
Postdrome:
Pain gradually subsides but residual tiredness, weakness, cognitive difficulties, muscle aches/tightness and mood changes can last from hours to days
Cranial arteritis- headache or pain caused inflammation of the arteries/blood vessels.
Fatigue, malaise, weight loss, fever
Usually will have inflammation-heat, redness, swelling, tenderness, pain over artery location
Visual problems may be caused ischemia of the involved structures
Management:
Provide individualized care and treatment
Prophylactic medications may be used for recurrent migraines
Migraines and cluster headaches requires abortive medications instituted as soon as possible with onset
Provide medications as prescribed
Provide comfort measures
Quiet, dark room
Massage
Local heat for tension
Nursing management:
Help patient identify triggers and develop a preventive strategies and lifestyle changes for headache prevention
Medication instruction and treatment regimen
Stress reduction techniques
Nonpharmacologic therapies
Follow-up care
Encouragement of healthy lifestyle and health promotion activities
Assessment:
A detailed description of the headache is obtained
Include medication history and use
The types of headaches manifest differently in different persons and symptoms in one individual may also may change over time
Although most headaches do not indicate serious disease, persistent headaches require investigation
Persons undergoing a headache evaluation require a detailed history and physical assessment with neurologic exam to rule out various physical and psychological causes
Diagnostic testing may be used to evaluate underlying cause if there are abnormalities on the neurologic exam
Prevention:
begins by having the patient avoid specific triggers that are known to initiate the headache syndrome
Preventive medical management of migraine involves the daily use of one or more agents that are thought to block the physiologic events leading to an attack. Treatment regimens vary greatly, as do patient responses; therefore, close monitoring is indicated.
Alcohol, nitrites, vasodilators, and histamines may precipitate cluster headaches. Elimination of these factors helps prevent the headaches.
Medical Management Therapy for migraine headache is divided into abortive (symptomatic) and preventive approaches. The abortive approach, best used in those patients who have less frequent attacks, is aimed at relieving or limiting a headache at the onset or while it is in progress.
The preventive approach is used in patients who experience more frequent attacks at regular or predictable intervals and may have a medical condition that precludes the use of abortive therapies
Medical management of migraine during pregnancy and lactation includes nonpharmacologic strategies in addition to safe medication practices
Nonpharmacologic treatments include mainly avoidance of triggers
The triptans, which are serotonin receptor agonists, are the most specific antimigraine agents available. These agents cause vasoconstriction, reduce inflammation, and may reduce pain transmission. The five triptans in routine clinical use include sumatriptan (Imitrex), naratriptan (Amerge), rizatriptan (Maxalt), zolmitriptan (Zomig), and almotriptan (Axert) (D’Arcy, 2014). Numerous serotonin receptor agonists are under study. Many of the triptan medications are available in a variety of formulations, such as nasal sprays, inhalers, conventional tablet, disintegrating tablet, suppositories, or injections. The nasal sprays are useful for patients experiencing nausea and vomiting
The triptans are considered first-line treatment of the management of moderate to severe migraine pain. Best results are achieved with early use of triptans; oral dosing takes effect within 20 to 60 minutes of taking the drug and if needed may be repeated in 2 to 4 hours. Triptans are contraindicated in patients with ischemic heart disease. Careful administration and dosing instructions to patients are important to prevent adverse reactions such as increased blood pressure, drowsiness, muscle pain, sweating, and anxiety. The medical management of cranial arteritis consists of early administration of a corticosteroid to prevent the possibility of loss of vision due to vascular occlusion or rupture of the involved artery. The patient is instructed not to stop the medication abruptly, because this can lead to relapse. Analgesic agents are prescribed for comfort.
Nursing care:
during an attack includes comfort measures such as a quiet, dark environment; elevation of the head of the bed to 30 degrees; and symptomatic treatment (i.e., administration of antiemetic medication) (Hickey, 2014).
Symptomatic pain relief for tension headache may be obtained by application of local heat or massage. Additional strategies may include administration of analgesic agents, antidepressant medications, and muscle relaxants.
Education regarding prevention:
Be aware of the definition of migraine headaches along with the characteristics and manifestations.
Recognize triggers of migraine headaches and how to avoid such triggers as:
Foods that contain tyramine, such as chocolate, cheese, coffee, dairy products
Dietary habits that result in long periods between meals
Menstruation and ovulation (caused by hormone fluctuation)
Alcohol (causes vasodilation of blood vessels)
Fatigue and fluctuations in sleep patterns
Develop and use a paper or electronic headache diary.
Implement stress management and lifestyle changes to minimize the frequency of headaches.
Ensure correct pharmacologic management: acute therapy and prophylaxis to include medication regimen and side effects.
Use comfort measures during headache attacks, such as resting in a quiet and dark environment, applying cold compresses to the painful area, and elevating the head.
Seek out resources for education and support, such as the National Headache Foundation.
Trigeminal Neuralgia
A condition of the 5th cranial nerve that is characterized by a sudden attack of pain in the area innervated by any of the 3 branches. Pain ends as abruptly as it starts.
Characterized as a unilateral shooting, stabbing, or burning sensation.
Associated involuntary contraction of the facial muscles can cause sudden closing of the eye or twitching of the mouth.
More common 50s-60s, more common in women and in people with MS (multiple sclerosis)
Pain-free intervals may be measured in terms of minutes, hours, days, or longer. Painful episodes tend to become more frequent and agonizing.
Can occur with any stimulation of the terminals of the affected nerve branches, such as washing the face, shaving, brushing the teeth, eating, and drinking. A draft of cold air or direct pressure against the nerve trunk may also cause pain. Certain areas are called trigger points because the slightest touch immediately starts a paroxysm or episode. To avoid stimulating these areas, patients with trigeminal neuralgia try not to touch or wash their faces, shave, chew, or do anything else that might cause an attack. These behaviors are a clue to the diagnosis.
Treatment:
Medications:
Anticonvulsants-carbamazepine, gabapentin, phenytoin (reduces transmission of impulses at certain nerve terminals)
Baclophen-muscle relaxant, adjunctive for pain control
Surgical interventions:
May relieve pain for a few years, recurrence is high. Procedures aimed at decompressing the nerve to preserve function or destroying the nerve to keep it from malfunctioning.
Microvascular decompression of the trigeminal nerve
Radiofrequency thermal coagulation-Gamma knife radiosurgery is a noninvasive method of delivering focused radiation to the trigeminal nerve; it requires 6 to 8 weeks of treatment for maximal effect to occur
Percutaneous balloon micro compression
Nursing Management:
Assessment and prevention of pain
Recognizing triggers- prevention is key in pain/symptom control
Providing cotton pads and room temperature water for washing the face, instructing the patient to rinse with mouthwash after eating if tooth brushing causes pain, and performing personal hygiene during pain-free intervals are all effective strategies. The patient is instructed to take food and fluids at room temperature, to chew on the unaffected side, and to ingest soft foods.
Goals:
Give the most nutrition in the smallest amount that you can (ensure, protein cups)
Cluster activities
Pain can go to numbness- pain block – anytime there is numbness, worry about injury
Face has a lot of injury potential
Providing post-operative care:
Postoperative neurologic assessments are conducted to evaluate the patient for facial motor and sensory deficits in each of the three branches of the trigeminal nerve.
If the surgery results in sensory deficits to the affected side of the face, the patient is instructed not to rub the eye because the pain of a resulting injury will not be detected.
The eye is assessed for irritation or redness.
Artificial tears may be prescribed to prevent dryness in the affected eye.
The patient is cautioned not to chew on the affected side until numbness has diminished.
The patient is observed carefully for any difficulty in eating or swallowing foods of different consistencies.
Bell’s Palsy
Facial paralysis is caused by unilateral inflammation of the seventh cranial nerve, which results in weakness or paralysis of the facial muscles on the affected side.
The face is distorted from paralysis of the facial muscles; decreased lacrimation (tearing) occurs; and the patient experiences painful sensations in the face, behind the ear, and in the eye. The patient may also experience speech difficulties and may be unable to eat on the affected side because of weakness or paralysis of the facial muscles.
Most common in adults under 45
Majority of patients recover completely and Bell palsy rarely recurs
cause is unknown, theories include vascular ischemia, viral disease (herpes simplex, herpes zoster), autoimmune disease, or a combination of all of these factors
One sided face paralysis
Less tearing, ability to control blinking (dryness, injury)
Last weeks to months and then goes away
Treatment:
focus is to maintain the muscle tone of the face and to prevent or minimize denervation. The patient should be reassured that no stroke has occurred and that spontaneous recovery occurs within 3 to 5 weeks in most patients.
Medications
Corticosteroids- prednisone- reduce inflammation and edema
Reduces pain and prevents or minimizes denervation
Analgesics- reduces pain
Electrical stimulation- prevents muscle atrophy
Surgical exploration- indicated if tumor suspected for decompression of the nerve.
Nursing management:
While paralysis is present, nursing care involves protection of the eye from injury. The eyelid does not close completely and the blink reflex is diminished, so the eye is vulnerable to injury from dust and foreign particles. Corneal irritation and ulceration may occur.
To prevent injury, the eye should be covered with a protective shield at night/eye patch
Moisturizing eye drops during the day and eye ointment at bedtime may help prevent injury
The patient can be educated to close the paralyzed eyelid manually before going to sleep.
Wraparound sunglasses or goggles may be worn during the day to decrease evaporation from the eye.
After the sensitivity of the nerve to touch decreases and the patient can tolerate touching the face, the nurse can suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.
Facial exercises, such as wrinkling the forehead, blowing out the cheeks, and whistling, may be performed with the aid of a mirror to prevent muscle atrophy.
Exposure of the face to cold and drafts is avoided.
Peripheral Neuropathy
A disorder affecting the peripheral motor and sensory nerves, usually beginning in the feet and hands, characterized by bilateral and symmetric disturbance of function.
Most common cause of peripheral neuropathy is diabetes with poor glycemic control
Major symptoms: loss of sensation muscle atrophy Weakness diminished reflexes Pain paresthesia of the extremities
Diagnosed by history, physical examination, and electrodiagnostic studies such as EEG or EMG.
Treatment:
No specific treatment, treatment focuses on prevention and slowing progression of disease through control of causative factors like maintaining good glycemic control in diabetic patients.
Nursing Management
Education!!!
Patients with peripheral neuropathy are at risk for falls, thermal injuries, and skin breakdown.
Inspection of the lower extremities for skin breakdown, foot care and follow up!
Assistive devices such as a walker or cane may decrease the risk of falls.
Bathwater temperature is checked to avoid thermal injury.
Footwear should be accurately sized.
Driving may be limited or eliminated, thereby disrupting the patient’s sense of independence.
Preventing injury-
Wear shoes all the time
Check feet daily- hard time with wound healing
See provider/Pediatrist every 3 months- follow progression (EMG)
