WEEK 3: STROKE IN THE ELDERLY Flashcards
1
Q
ISCHAEMIC STROKE
A
- Blockage of blood vessels supplying the brain
- 4 out of 5 strokes are ischaemic
- Embolic: clot forms and travels to the brain
- Thrombotic: Plaques form
Transient Ischemic Attack: (Mini stroke)
- Temporary blockage of blood vessels supplying the brain
- Can be precursor to a stroke. ⅕ will have a major stroke within the next 3 months→ don’t ignore
- Strokes are the 3rd leading cause of death in Australia
2
Q
HAEMORRHAGIC STROKE
A
- Blood vessel rupture causing bleeding into the brain
- 1 out of 5 strokes are hemorrhagic
- Intracerebral haemorrhage
- Subarachnoid haemorrhage
3
Q
STROKE AND THE ELDERLY
A
- Cerebral amyloidosis- amyloid deposits (70’s)
- Atherosclerotic changes
- Decrease in function of baroreceptors (heart rate and blood pressure)
- Ageing and wear and tear
- Neurological loss and shrinkage, loss of synapses (connections between neurons)
- Reduction in new neuronal growth- reduce the ability to recover from insult
- Reduction in neurotransmitters
- Decreased cerebral blood flow and cerebral metabolic rate (more than 25% by 80’s)
- Decreased pathways, procession speed
4
Q
STROKE RISK FACTORS: NO CONTROL
A
- Age
- Gender
- Family history
5
Q
STROKE RISK FACTORS:
A
- TIA
- AF- Atrial fibrillation
- Diabetes
- Fibromuscular dysplasia
6
Q
STROKE RISK FACTORS:
A
- Hypertension
- Hyperlipidemia
- Smoking
- Obesity/ Inactivity
- Alcohol intake
7
Q
STROKE PREVENTIONS (FAST)
A
- 80% of strokes can be prevented
F.A.S.T→Signs and symptoms
- Facial drooping
- Arm weakness
- Speech difficulties
- Time to call 000
8
Q
STROKE PROCEDURAL: ISCHARMIC
A
- Thrombolysis
- Endovascular clot retrieval
- Carotid endarterectomy
9
Q
STROKE PROCEDURAL: HAEMORRHAGIC
A
- Craniotomy and repair of vascular abnormality
- Endovascular repair of vascular abnormality
10
Q
STROKE PROCEDURAL: THROMBOLYSIS- TISSUE PLASMINOGEN ACTIVATOR (TPA)
A
- Intravenous alteplase should be administered as early as possible (within the first few hours) after stroke onset but may be used up to 4.5 hours after onset
Contraindicated
- Haemorrhagic stroke
- Large area of ischaemic stroke on imaging (>⅓)
- Active bleeding, recent history of trauma or surgery
- Coagulopathy, decreased platelet count , Increased INR
- Anticoagulants within 48hrs
11
Q
MEDICATION MANAGEMENT: ISCHAEMIC
A
- Antiplatelet
- Antihypertensive
- Anticoagulants
- Statins
12
Q
MEDICATION MANAGEMENT: HAEMORRHAGIC
A
Antihypertensive
13
Q
NURSING CONSIDERATIONS: REMEMBER THE ANATOMY
A
- Swallow deficits (dysphagia) high aspiration risk- swallow assessment within 4 hours or prior to oral intake
- Oral hygiene
- High falls risk, decreased morbidity
- Risk of VTE- immobility
- Spasticity and contractures
- Early hydration/nutrition assessment support where required
- Communication deficits- aphasia
- Fatigue/depression
- Adherence to preventive pharmacotherapy
14
Q
INDICATIONS FOR URINARY CATHETERISATION
A
- Relieve urinary retention acute/chronic
- To empty the bladder prior to surgery/investigations
- To instil medication
- Determine residual volume in the absence of u/sound equipment
- Irrigate the bladder
- To keep the perineal area dry to assist healing
- Determine accurate fluid balance
- To collect a sterile specimen of urine
- For investigations of the lower urinary tract. E.g. Urodynamics
- Management of intractable incontinence
- Instrument delivery
- To allow healing following lower urinary tract surgery
- Comfort for the terminally ill
15
Q
FEMALE URINARY CATHERTIRISATION: EQUIPMENT
A
- Gloves (clean and sterile)
- Light source (if needed)
- Catheter pack
- Catheter (size)
- Waterproof sheet (bluey)
- Adhesive tape, scissors
- Drainage system
- Goggles, apron
- Waste bag
16
Q
FEMALE URINARY CATHERTIRISATION: PROCEDURE
A
- Washes hands, cleans trolley and gathers equipment for catheterisation
- Establishes sterile field without contamination
- Dons apron, goggles and places bluey under patient, drapes patient, organises position and drainage system
- Invasive procedure hand wash, dons sterile gloves
- Prepares equipment on sterile field, tests balloon
- Cleans inner vulva and urinary meatus
- Inserts urinary catheter without any contamination
- Inflates balloon
- Attaches drainage system and secures
- Drains perineal area, repositions patient, ensures comfort
- Disposes of equipment appropriately
- Washes hands
- Documents relevant information
17
Q
DYSPHAGIA
A
- A disorder/ symptom that can be caused by structural, physiological and/or neurological impairment→ affects preparatory, oral, pharyngeal and/or esophageal stages
- Any difficulty moving food from mouth to stomach
Impacts→
- Aspiration pneumonia
- Malnutrition and dehydration
- Increased length of hospital stay
- Increased mortality and disability
- Higher chance of going to residential care at discharge
- Very common in acute stroke→ patients should be screened for swallowing deficits before being given food/drink/oral medication
18
Q
PHASES OF NORMAL SWALLOW: (4)
A
1) Oral preparatory phase (Voluntary)
2) Oral phase (Voluntary)
3) Pharyngeal phase (Involuntary)
4) Oesophageal Phase (Involuntary)
19
Q
PHASES OF NORMAL SWALLOW: Oral preparatory phase (Voluntary)
A
- Prepares the mouth for the bolus and fluid
- The larynx and pharynx are relaxed
- Airway is open
- Requires senses of taste, temperature and touch for formation of a bolus to the right size and consistency
20
Q
PHASES OF NORMAL SWALLOW: Oral phase (Voluntary)
A
- Begins with placement of food in the mouth
- Lips/Cheeks seal- food is chewed, mixed with saliva and gathered to form the bolus
- Soft palate rests against back of tongue
- The larynx and pharynx are at rest and the airway is open
- Initiated when the tongue begins to move the bolus towards the pharynx
- Once the bolus reaches the pharynx the oral stage of the swallow is terminated
21
Q
PHASES OF NORMAL SWALLOW: Pharyngeal phase (Involuntary)
A
- Begins with the triggering of the swallow reflex
- Breathing is suspended
- Soft palate meets pharyngeal wall
- Larynx elevates and airway seals
- Bolus squeezed through oropharynx
- Upper esophageal sphincter opens to allow food into oesophagus
22
Q
PHASES OF NORMAL SWALLOW: Oesophageal Phase (Involuntary)
A
- Closure of upper esophageal sphincter to prevent regurgitation
- The hyoid bone is released and moves back to its resting position
- The individual breaths out
- Food moves down toward stomach
23
Q
ORAL DYSPHAGIA
A
- Reduced awareness of the bolus/ Poor bolus control and formation
- Lip weakness
- Slow and laboured chewing
- Oral residue
24
Q
PHARYNGEAL DYSPHASIA
A
- Delayed or absent swallow reflex
- Premature spillage into pharynx
- Penetration into the larynx
- Pharyngeal pooling
- Reduced laryngeal excursion
25
ASPIRATION
- Refers to the passing of food or fluid below the level of the vocal folds toward the lungs
- Commonly occurs from impairment in the swallow function
- Can be overt or silent
- May result in aspiration pneumonia → infection of the lungs and bronchial tubes→ caused by aspiration of foreign material such as food, fluid or saliva
26
PRINCIPLES OF PERSON CENTRED CARE (4)
- Know the patient as a person
- Share the power and responsibility in care
- Make services accessible and flexible
- Enrich the care environment
27
PRINCIPLES OF PERSON CENTRED CARE: Know the patient as a person
- Build a relationship with the person and their family/carer
- Getting to know the person beyond their diagnosis
28
PRINCIPLES OF PERSON CENTRED CARE: Share the power and responsibility in care
- Respect preferences
- Treat the person and their family/carer as partners when setting goals, planning care and making decisions about care, treatment and outcomes
29
PRINCIPLES OF PERSON CENTRED CARE: Make services accessible and flexible
- Meet the person’s individual needs by acknowledging their values, preferences and needs
- Whilst giving the accurate and appropriate info, so they can make informed choices about their care
30
PRINCIPLES OF PERSON CENTRED CARE: Enrich the care environment
- Identify the relationships between the human and physical environments and the older person’s health behaviour and actions
- Adjust the physical, organisational and socio-cultural environment to enable staff to be person centred in the way they work
31
REASONS FOR INSERTION OF AN NGT
- Removal of gastric contents
- Introduction of feed or medication
- Prevent nausea, vomiting and gastric distention following surgery or if there is an obstruction of the GI tract
- Remove stomach contents for laboratory analysis
- Lavage (wash) the stomach in cases of poisoning or overdose of oral medications
- An X-ray is required to confirm NGT placement
32
DAILY NGT CARE
- Inspect the nostril for discharge and irritation
- Cleanse the nostril and tube with moistened, cotton-tipped applicators
- Apply water-soluble lubricant to the nostril if it appears dry or encrusted
- Change the adhesive tape as required to secure the tube and prevent skin trauma from either tape or pressure of the tube against the nares
- Provide frequent mouth care→ due to the presence of the tube; person may breathe through the mouth
- Keep accurate records of the person’s fluid intake and output and record the amount and characteristics of the drainage
33
CONTRAINDICATIONS FOR NGT INSERTION IN PATIENTS WITH
- Fractured base of skull or severe facial/nasal injuries→ tube may enter cranium
- Suspected esophageal varices (particularly in alcoholic liver disease) → risk of vein rupture
- Upper GIT obstruction
- Post op recovery from gastrectomy, esophagectomy, head and neck surgery
- Suspected spinal injury (manipulation of neck during insertion procedure)
34
RANGE OF NGT TUBES
- Salem sump tube→ Double lumen→ allows suction and removal of gastric contents, with smaller lumen allows for inflow of air to prevent vacuum being created in the stomach
- Small bore feeding tube→ Used for feeding, softer and easier to insert and more appropriate for longer term use
35
MANAGING A PEG SITE
- Assess skin frequently for irritation or breakdown
- Wash peristomal skin with mild soap and water daily
- Rotate tube between thumb and forefinger to release any sticking and promote tract formation
- Petroleum, zinc oxide ointment or other barrier cream applied around the stoma
- Cover coiled tube with pre-cut square gauze
- Apply tape to secure dressing
36
PEG SITE MEANING
PERCUTANEOUS ENDOSCOPIC GASTROSTOMY)
37
PRINCIPLES OF GASTROSTOMY MEDICATION ADMINISTRATION
- Medical officer documented that medication needs to be crushed or capsules opened
- Medication crushing procedure is informed by a pharmacist
- Consistency of medication and size of tubing are considered to determine ease of administration
- Medication administered through correct port with a non-luer dispensing syringe
- Tube is flushed with water before and after administrations of meds and between meds to reduce blockages
- Meds taken on an empty stomach should be taken 30 mins before feeds, or 2 hours after feeds
38
RISK FACTORS ASSOCIATED WITH INCONTINENCE
- Age
- Obesity
- Pregnancy, childbirth
- Prostate cancer, prostate disease and prostate surgery
- UTI
- Diabetes
- Cognitive impairment and dementia
- Menopause
- Neurological disorders
- Chronic illness
- Mobility impairment
39
Stress Incontinence
- Involuntary loss of urine on stress, exertion, coughing or sneezing.
- Small amounts of urine loss
40
Urgency Urinary Incontinence
- Involuntary loss of urine associated with an urgency to void
- Moderate to large amounts of urine loss
41
Mixed Urinary Incontinence
- Involuntary loss of urine associated with urgency and on stress or exertion
42
Nocturnal Enuresis
- Involuntary loss of urine during sleep
43
Post Micturition Dribble
- Involuntary loss of urine immediately after voiding
| - Usually men
44
Continuous Urinary Leakage
- Ongoing loss of urine, not dependent on position or movement
45
Overactive Bladder
- Urgency (with and without urge incontinence) and usually frequency and nocturia
46
Functional Incontinence
- Urinary incontinence without obvious structural or neurological abnormality of the urinary tract or gastrointestinal tract.
- Inability to respond in an appropriate way to the urge to urinate or defecate
47
INCONTINENCE & MANAGEMENT
```
- Not a normal part of ageing
Management
- Assessment to determine cause→ voiding diaries
- Bladder and bowel training
Pelvic floor muscle exercises
- Prompted toileting
- Dietary modifications
- Pharmacological management
- Continence aids and appliances
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48
CONSTIPATION
- Complaints of difficulty (straining) passing stool (hard)
| - Incomplete passage of stool and diminished frequency of bowel actions
49
CONSTIPATION COMPLICATIONS: GASTROINTESTINAL
- Impaction
- Obstruction
- Megacolon
- Fecal incontinence
- Rectal distension
- Rectal prolapse
- Haemorrhoids
- Anorexia and vomiting
50
CONSTIPATION COMPLICATIONS: UROLOGICAL
- Retention
| - Incontinence
51
CONSTIPATION COMPLICATIONS: CARDIAC AND VASCULAR
- Arrhythmias
- Vasovagal episode
- Angina
- Pulmonary emboli
52
CONSTIPATION COMPLICATIONS: OTHER
- Delirium
- Laxative abuse
- Anxiety
53
CONSTIPATION MANAGEMENT: PHARMACOLOGICAL
- Patient history and physical exam
- Instigate preventative measures in combination with pharmacological management
- Avoid regular use of rectal preparations
- General combination of a softener and a stimulant
- Titrate aperients according to response
54
CONSTIPATION MANAGEMENT: NON- PHARMACOLOGICAL
- Diet
- Exercise
- Bowel training
- Toileting position
55
DIARRHOEA
- Is a passage of liquid and unformed faeces and is a symptom of disorders affecting digestion, absorption and secretion in the gastrointestinal tract
- Can result in serious fluid and electrolyte imbalances
56
DIARRHOEA CAUSES
- Intestinal infection- virus, bacteria and parasite
- Colon disease- Crohns, ulcerative colitis
- Food allergies/ intolerances
- Medications- laxatives, diuretics, lithium, thyroxine and chemotherapy
- Enteral feeding
- IBS
- Surgical alteration- gastrectomy, colon resection
