Med Surg Exam #3 Study Guide
Alzheimer’s disease and the management; nursing care of the patient with Alzheimer’s
What is it: AD is a progressive, irreversible degenerative neurologic disease that begins insidiously and is characterized by gradual
loss of cognitive function and disturbances in behavior and affect. Aka senile dementia – most common form of dementia.
Uncommon before 65 – prevalence increases with age – 30% of those 85 and older. Affect about 4.5 million people in U.S. – some
research suggests that oxidative stress plays a role in pathophysiology.
Clinical Manifestations:
Early stages: forgetfulness and subtle memory loss, small difficulties in work or social activities. Pt can usually hide the loss of function
– can start to become depressed.
Further progression is obvious – s/s cannot be hidden.
Forgetfulness in daily activities, lost ability to recognize familiar faces, places, objects and become lost in familiar environments.
Repeat things often, conversations are difficult and word finding occurs. The ability to formulate concepts and think abstractly
disappears. Everything is literal – concrete. Pt’s are unable to recognize consequences and exhibit impulsive behavior.
Personality changes such as depression, suspicion, paranoia, hostility, and combative behaviors.
Progression eventually leads to speaking skills deteriorate to nonsense, agitation and wandering. Pts need assist in all ADL’s.
Terminal stage – patients are immobile, require total care, and death usually results from complications such as: PNA, malnutrition, and
dehydration.
Nursing Management:
Nursing interventions are aimed at promoting patient function and independence as long as possible and safe for patient.
Supporting Cognitive Function: Active participation in cognitive, functional and social interaction, physical activities and
communication. Calm predictable environment, quiet pleasant speaking, clear and simple explanation’s, memory aids and
cues.
Promoting Physical Safety: Making sure the patient has a safe home environment where they can move about freely is most
important. Removing obvious hazards, installing hand-rails, adequate lighting, and nightlights. Wandering behavior can be
reduced by general distraction. Restraints should be avoided due to agitation. All activities outside of the home should be
supervised and pt should wear and id bracelet incase of separation from caregiver.
Promoting Independence in Self-Care activities: Patients should be assisted to remain as functionally independent as
possible. Simply daily activities by organizing into short, achievable steps so they can experience accomplishment. Direct
supervision is sometimes necessary but maintaining personal dignity and autonomy is important.
Reducing Anxiety and Agitation: Patients can be aware of their diminished abilities so its important to give constant
emotional support to reinforce positive self image. Its important to adjust goals according to their declining ability. Keep the
environment familiar and noise free. Too much excitement and confusion can be upsetting and cause combative agitated
state.
Improving Communication: Use clear easy explanations that are unhurried. Reduce noise and distraction when talking with
them.
Providing for Socialization and Intimacy Needs: Socialization with friends can be comforting, but should be brief and non
stressful. Reduce overstimulation. Recreation is important but must be realistic.
Promoting Adequate Nutrition: Patients prefer food that is familiar and that look good to eat, food should be cut into small
pieces and one dish offered at a time to prevent choking. Food should be served warm and checked prior to eating to prevent
burns. Patients may need to use fingers or spoons to assist them in eating, if they are not total care. Uses of aprons are
preferred to bibs to maintain dignity.
Promoting Balanced Activity and Rest: Adequate sleep and physical activities are essential.
, Supporting Home and Community Based Care: Emotional support is needed for both family and patient as the
degenerative disorder progresses. Patients can be aggressive and combative and families do not know how to cope. It’s vital
to utilize services that provide families with support groups, education, research and advocacy.
Lumbar puncture/MRI/CT nursing role
Lumbar puncture: AKA Spinal Tap
What is it: Process includes inserting a needle into the lumbar subarachnoid space (L3-L4 OR L4-L5) to withdraw CSF. It can be
done to examine CSF, reduce CSF pressure, determine presence or absence of blood, and to administer meds intrathecally.
It important for patient to remain relaxed, a patient who is anxious will have abnormal CSF pressure readings.
Normal CSF pressure = 50-200mm h20
CSF should be clear and colorless. Pink, frothy, bloody, may indicate a subarachnoid hemorrhage. It can also be bloody initially
because of the initial trauma but as you aspirate it will clear up.
Positioning: Patient is placed in lateral recumbent position (laying on side with either one knee/both flexed up to chest as much as
possible to increase space between the spinous process of the vertebrae and easier access to subarachnoid space).
Pre-procedure: Obtain consent. Explain the procedure to the patient and all sensations (cold while cleaned, small prick when needle
inserted, etc). Reassure the patient that the needle does not enter the spinal cord and does not cause paralysis. Determine whether the
patient has fully understood and if there are any more questions. Patient should void before procedure.
Procedure: patient is positioned on one side of the edge of the bed in a lateral recumbent position with knees flexed to increase the
space between the spinous processes for easier entry. Nurse assists in maintaining the position and preventing sudden movements.
Patient is instructed to relax and breathe normally because hyperventilation can cause differences in pressures. The nurse describes
the procedure step by step. Physician cleanses the site, drapes the area, and administers local anesthetic. A needle is then inserted
where a pressure at that moment can be obtained. A specimen is removed, labeled, and then the needle is removed. The specimens
are walked up to the lab immediately.
Post-Procedure: instruct the patient to lie in the prone position for 2-3hrs to reduce leakage of CSF. Increase fluid intake to prevent
post-op headache, which is caused by leakage at the puncture site. Monitor for complicates such as bleeding, leakage of fluid, changes
in LOC. If larger volumes of CSF are removed, to avoid post lumbar puncture headache, the patient should lie prone for 2 hours, the
flat in a side-lying position for 2-3 hours, and then supine or prone for another 6 hours.
CT Scan: Computed Tomography Scanning
CT uses a narrow x-ray bean to scan the body part in successive layers. It is non-invasive and painless and has a high degree of
sensitivity for detecting lesions. It usually preformed first without contrast material and then with IV contrast to enhance. The patient
lies on an adjustable table with the head held in a fixed position.
Nursing Interventions:
oTeaching regarding procedure and about the need to lie still
oAssess for Allergies to iodine if having IV contrast
oAssess renal function
oMonitor for side effects including flushing, nausea, and vomiting
MRI: Magnetic Resonance Imaging
MRI uses a powerful magnetic field to obtain images of different areas of the body. It involves altering hydrogen ions in the body.
Nursing Interventions:
oTeaching regarding procedure
oAll metal objects must be removed
oPatient HX obtained for metal objects in body
, oSedation if needed for pt’s with claustrophobia
Guillain-Barre/MS/MG-Clinical manifestations and nursing role
Guillian-Barre Syndrome
What is it: It is an ascending autoimmune disorder, which attacks the peripheral nerve myelin. It produces ascending weakness w/
dyskinesia (inability to execute voluntary movements), hyporeflexia, and parathesias (pins and needles sensation).
Pathophysiology:
Most commonly caused by a virus or parasite such as Epstein-Barr virus, Cytomegalovirus, HIV, or Camplylobacter jejuni.
Involves demyelination or axonal degeneration of multiple peripheral nerves that leads to symmetric sensory, motor, or mixed
sensorimotor deficits. Typically, the longest axons are involved first, with symptoms beginning in the distal part of the extremities.
It is a result of a cell-mediated and humeral immune attack on peripheral nerve myelin proteins that cause s inflammatory
demyelination. The immune system cannot distinguish between the infectious organism and the actual peripheral nerve myelin protein
and results in the immune system attacking and destroying the peripheral nerve myelin and leave the nerve unable to support
conduction.
Although the myelin is damaged at first the patient can recover from this and the myelins will be remyelinated during the recovery
phase (duration is variable but could be up to 2 years for full recovery)
Does not effect LOC or cognitive function
Diagnosis is usually made by history of a previous viral illness & elevated proteins levels in CSF, and patient presentation of symptoms.
Clinical Manifestations:
The disease first presents with symmetrical muscle weakness and diminished reflexes in the lower extremities. It then progresses to
tetraplegia. This is ascending degeneration (from the legs up)
Paralysis, Parethesias, and Pain caused by the demyelination.
Neuromuscular respiratory failure from the demyelination of the nerve fibers that innervate the diaphragm and the lungs
Bulbar weakness – inability to swallow or clear secretions. (Suctioning present to aid in maintaining a clear airway. )
Cranial nerve demyelination of the optic nerve can cause blindness
Vagus Nerve demyelination results in autonomic dysfunction, which manifests in the cardiovascular system as tachycardia,
bradycardia, hypertension, or orthostatic hypotension. Usually these symptoms occur and resolve rapidly.
Nursing Management:
Medical Emergency – Intensive Care Unit with continuous monitoring
Assess physical and respiratory needs of the patient, baseline vitals.
Respiratory therapy or mechanical ventilation may be necessary to support pulmonary function and adequate oxygenation. Some
clinicians suggest elective intubation even before the respiratory failure/depression occurs
Possibility of mechanical ventilation should be discussed on admission to aid with the psychological aspect of it. If it is initiated prior to
distress it results in less anxiety because the patient is well informed.
Prevent complications of immobility by administering anticoagulants and SCD to prevent thrombosis and PE.
Limbs are supported in functional positions and passive range of motion exercises are performed at least twice daily.
Position changes are important – every 2 hours and bony prominences may have padding applied to reduce the risk for pressure ulcers
Use of SCD’s and anti-embolism stockings, anticoagulation therapy can reduce the risk of DVT, PE, and VTE
Alzheimer’s disease and the management; nursing care of the patient with Alzheimer’s
What is it: AD is a progressive, irreversible degenerative neurologic disease that begins insidiously and is characterized by gradual
loss of cognitive function and disturbances in behavior and affect. Aka senile dementia – most common form of dementia.
Uncommon before 65 – prevalence increases with age – 30% of those 85 and older. Affect about 4.5 million people in U.S. – some
research suggests that oxidative stress plays a role in pathophysiology.
Clinical Manifestations:
Early stages: forgetfulness and subtle memory loss, small difficulties in work or social activities. Pt can usually hide the loss of function
– can start to become depressed.
Further progression is obvious – s/s cannot be hidden.
Forgetfulness in daily activities, lost ability to recognize familiar faces, places, objects and become lost in familiar environments.
Repeat things often, conversations are difficult and word finding occurs. The ability to formulate concepts and think abstractly
disappears. Everything is literal – concrete. Pt’s are unable to recognize consequences and exhibit impulsive behavior.
Personality changes such as depression, suspicion, paranoia, hostility, and combative behaviors.
Progression eventually leads to speaking skills deteriorate to nonsense, agitation and wandering. Pts need assist in all ADL’s.
Terminal stage – patients are immobile, require total care, and death usually results from complications such as: PNA, malnutrition, and
dehydration.
Nursing Management:
Nursing interventions are aimed at promoting patient function and independence as long as possible and safe for patient.
Supporting Cognitive Function: Active participation in cognitive, functional and social interaction, physical activities and
communication. Calm predictable environment, quiet pleasant speaking, clear and simple explanation’s, memory aids and
cues.
Promoting Physical Safety: Making sure the patient has a safe home environment where they can move about freely is most
important. Removing obvious hazards, installing hand-rails, adequate lighting, and nightlights. Wandering behavior can be
reduced by general distraction. Restraints should be avoided due to agitation. All activities outside of the home should be
supervised and pt should wear and id bracelet incase of separation from caregiver.
Promoting Independence in Self-Care activities: Patients should be assisted to remain as functionally independent as
possible. Simply daily activities by organizing into short, achievable steps so they can experience accomplishment. Direct
supervision is sometimes necessary but maintaining personal dignity and autonomy is important.
Reducing Anxiety and Agitation: Patients can be aware of their diminished abilities so its important to give constant
emotional support to reinforce positive self image. Its important to adjust goals according to their declining ability. Keep the
environment familiar and noise free. Too much excitement and confusion can be upsetting and cause combative agitated
state.
Improving Communication: Use clear easy explanations that are unhurried. Reduce noise and distraction when talking with
them.
Providing for Socialization and Intimacy Needs: Socialization with friends can be comforting, but should be brief and non
stressful. Reduce overstimulation. Recreation is important but must be realistic.
Promoting Adequate Nutrition: Patients prefer food that is familiar and that look good to eat, food should be cut into small
pieces and one dish offered at a time to prevent choking. Food should be served warm and checked prior to eating to prevent
burns. Patients may need to use fingers or spoons to assist them in eating, if they are not total care. Uses of aprons are
preferred to bibs to maintain dignity.
Promoting Balanced Activity and Rest: Adequate sleep and physical activities are essential.
, Supporting Home and Community Based Care: Emotional support is needed for both family and patient as the
degenerative disorder progresses. Patients can be aggressive and combative and families do not know how to cope. It’s vital
to utilize services that provide families with support groups, education, research and advocacy.
Lumbar puncture/MRI/CT nursing role
Lumbar puncture: AKA Spinal Tap
What is it: Process includes inserting a needle into the lumbar subarachnoid space (L3-L4 OR L4-L5) to withdraw CSF. It can be
done to examine CSF, reduce CSF pressure, determine presence or absence of blood, and to administer meds intrathecally.
It important for patient to remain relaxed, a patient who is anxious will have abnormal CSF pressure readings.
Normal CSF pressure = 50-200mm h20
CSF should be clear and colorless. Pink, frothy, bloody, may indicate a subarachnoid hemorrhage. It can also be bloody initially
because of the initial trauma but as you aspirate it will clear up.
Positioning: Patient is placed in lateral recumbent position (laying on side with either one knee/both flexed up to chest as much as
possible to increase space between the spinous process of the vertebrae and easier access to subarachnoid space).
Pre-procedure: Obtain consent. Explain the procedure to the patient and all sensations (cold while cleaned, small prick when needle
inserted, etc). Reassure the patient that the needle does not enter the spinal cord and does not cause paralysis. Determine whether the
patient has fully understood and if there are any more questions. Patient should void before procedure.
Procedure: patient is positioned on one side of the edge of the bed in a lateral recumbent position with knees flexed to increase the
space between the spinous processes for easier entry. Nurse assists in maintaining the position and preventing sudden movements.
Patient is instructed to relax and breathe normally because hyperventilation can cause differences in pressures. The nurse describes
the procedure step by step. Physician cleanses the site, drapes the area, and administers local anesthetic. A needle is then inserted
where a pressure at that moment can be obtained. A specimen is removed, labeled, and then the needle is removed. The specimens
are walked up to the lab immediately.
Post-Procedure: instruct the patient to lie in the prone position for 2-3hrs to reduce leakage of CSF. Increase fluid intake to prevent
post-op headache, which is caused by leakage at the puncture site. Monitor for complicates such as bleeding, leakage of fluid, changes
in LOC. If larger volumes of CSF are removed, to avoid post lumbar puncture headache, the patient should lie prone for 2 hours, the
flat in a side-lying position for 2-3 hours, and then supine or prone for another 6 hours.
CT Scan: Computed Tomography Scanning
CT uses a narrow x-ray bean to scan the body part in successive layers. It is non-invasive and painless and has a high degree of
sensitivity for detecting lesions. It usually preformed first without contrast material and then with IV contrast to enhance. The patient
lies on an adjustable table with the head held in a fixed position.
Nursing Interventions:
oTeaching regarding procedure and about the need to lie still
oAssess for Allergies to iodine if having IV contrast
oAssess renal function
oMonitor for side effects including flushing, nausea, and vomiting
MRI: Magnetic Resonance Imaging
MRI uses a powerful magnetic field to obtain images of different areas of the body. It involves altering hydrogen ions in the body.
Nursing Interventions:
oTeaching regarding procedure
oAll metal objects must be removed
oPatient HX obtained for metal objects in body
, oSedation if needed for pt’s with claustrophobia
Guillain-Barre/MS/MG-Clinical manifestations and nursing role
Guillian-Barre Syndrome
What is it: It is an ascending autoimmune disorder, which attacks the peripheral nerve myelin. It produces ascending weakness w/
dyskinesia (inability to execute voluntary movements), hyporeflexia, and parathesias (pins and needles sensation).
Pathophysiology:
Most commonly caused by a virus or parasite such as Epstein-Barr virus, Cytomegalovirus, HIV, or Camplylobacter jejuni.
Involves demyelination or axonal degeneration of multiple peripheral nerves that leads to symmetric sensory, motor, or mixed
sensorimotor deficits. Typically, the longest axons are involved first, with symptoms beginning in the distal part of the extremities.
It is a result of a cell-mediated and humeral immune attack on peripheral nerve myelin proteins that cause s inflammatory
demyelination. The immune system cannot distinguish between the infectious organism and the actual peripheral nerve myelin protein
and results in the immune system attacking and destroying the peripheral nerve myelin and leave the nerve unable to support
conduction.
Although the myelin is damaged at first the patient can recover from this and the myelins will be remyelinated during the recovery
phase (duration is variable but could be up to 2 years for full recovery)
Does not effect LOC or cognitive function
Diagnosis is usually made by history of a previous viral illness & elevated proteins levels in CSF, and patient presentation of symptoms.
Clinical Manifestations:
The disease first presents with symmetrical muscle weakness and diminished reflexes in the lower extremities. It then progresses to
tetraplegia. This is ascending degeneration (from the legs up)
Paralysis, Parethesias, and Pain caused by the demyelination.
Neuromuscular respiratory failure from the demyelination of the nerve fibers that innervate the diaphragm and the lungs
Bulbar weakness – inability to swallow or clear secretions. (Suctioning present to aid in maintaining a clear airway. )
Cranial nerve demyelination of the optic nerve can cause blindness
Vagus Nerve demyelination results in autonomic dysfunction, which manifests in the cardiovascular system as tachycardia,
bradycardia, hypertension, or orthostatic hypotension. Usually these symptoms occur and resolve rapidly.
Nursing Management:
Medical Emergency – Intensive Care Unit with continuous monitoring
Assess physical and respiratory needs of the patient, baseline vitals.
Respiratory therapy or mechanical ventilation may be necessary to support pulmonary function and adequate oxygenation. Some
clinicians suggest elective intubation even before the respiratory failure/depression occurs
Possibility of mechanical ventilation should be discussed on admission to aid with the psychological aspect of it. If it is initiated prior to
distress it results in less anxiety because the patient is well informed.
Prevent complications of immobility by administering anticoagulants and SCD to prevent thrombosis and PE.
Limbs are supported in functional positions and passive range of motion exercises are performed at least twice daily.
Position changes are important – every 2 hours and bony prominences may have padding applied to reduce the risk for pressure ulcers
Use of SCD’s and anti-embolism stockings, anticoagulation therapy can reduce the risk of DVT, PE, and VTE
