Exam 1 Med Surg Galen

What are the three main types of headaches? - Migraine, Tension, Cluster Steps to Pain Assessment – Provoking Quality Radiation Severity Time Provoking - has anything made it better or worse Quality - Sharp, dull, achy, throbbing Radiation - Does it radiate to another part of the body Severity - Pain scale, 1-10 scale, intense pain, Other symptoms: N/V, photophobia Time - how long has it been going on? how long does it usually last? Tension Headache - Bandlike, tightness Describe a Migraine - Unilateral, supra and retro orbital, pulsating or throbbing, worse with movement, sensitivity with light and sounds Cluster - Lancinationg or stabbing, 5-30 minutes. Extreme pain Migraine Pathophysiology - Pathophysiology - Not entirely clear.; theories? Prevalence: May be seen in children and adults; Among children more common in boys; among adults more common in women. History of patient with migraine: Otherwise healthy, usually female in 30's Individualized triggers (stress, smells, foods, hormones, menses) Tyramine rich foods- chocolate, cheeses, beer, wine, cigar, sweet and low. Treatment for Migraine - Vasoconstriction works the best, irritation of the 5th cranial nerve, Estrogen hormone can causes migraines. Migraine Manifestations - Manifestations Pain: Usually unilateral, supra/retro-orbital, pulsating. Worse with movement. Accompanied by non-h/a symptoms: N/V, photophobia, phonophobia, Aura: (20% of cases): Migraine Interventions - Pain management Symptom management Ex. Pitch black, turn off all the lights, N/V causes dehydration Migraine Drug Therapy - APAP/Caffeine/ Butabital (Fioricet) NSAIDS : Naprosyn CCBs and Beta- Blockers (Preventative therapy) : Verapamil Triptans and ergotamine's: Sumatriptan and Cafergot Anticonvulsants (Preventative therapy): Topiramate Botox Injections (monthly) Magnesium Migraine Complementary and alternative therapies - Acupuncture, Yoga, Stress reduction activities, Supplemental mag, Distraction sometimes works. Pound acronym - P:Pulsating O:Duration U: Unilateral location N: N/V D: Disabling Epilepsy - Chronic disorder with two or more seizures experienced by the client. Epilepsy Assessment - Inquire about the seizure activity, frequency, precipitating factors, aura (pre-ictal phase). Family history Collateral medical conditions (hx stroke, HTN, TBI, drug/alcohol abuse) Seizure risk factors - V: Vascular I: Infection or Inherited conditions T: Trauma A: Alzheimers/Autoimmune M: Metabolic derangements I: Idiopathic N: Neoplasm S: pSychiatric Epilepsy Triggers - Sleep deprivation Stress Alcohol/ Alcohol Withdrawl MSG pg 878 Chart 42-9 Aura - Seizures often preceded by an aura; it is unique to that patient, not every patient has them. Somatic: rising epigastric sensation Hallucinations: Visual, gustatory, olfactory Halos, Zig-zags, h/a, paresthesias, psychiatric phenomenon, deja-vu Epilepsy Partial: - Partial (also called focal or local seizures): Occurs in a specific part of the brain. May be characterized by automatism or tic. Ex: Jerk, reflex, lip smacking (complex) Epilepsy Simple: - Client does not consciousness. Localized jerking/movement. Strange sensations. Autonomic symptoms. Focal awareness they do not lose consciousness. Epilepsy Complex - Involves altered LOC; may or may not have total loss of consciousness. Automatisms. Patient may wander at start or have amnesia after. Most common among older adults and difficult to diagnose bc symptoms appear similar to those of dementia, psychosis, or neurobehavioral disorder, esp post-ictal. Generalized epilepsy - Affects brain as a whole, bilateral seizure; we differentiate them based on how they appear while observing them. absence epilepsy - (petit mal): Generalized seizure involving sudden, brief loss of consciousness. Usually diagnosed in children. Appears as if they are staring off into space. Lasts seconds. tonic-clonic epilepsy - "Grand mal." Stereotypical body convulsions. Lasts minutes, involves muscle rigidity and convulsions. Tonic=stiffening, Clonic=jerking Myoclonic Epilepsy - Brief muscle jerks, lasts seconds Atonic (akinetic) Seizure (drop seizure) - Involves brief loss of tone. May be confused with Fainting. Acute Seizure Management (Observation) - History (if reported) Look for underlying cause! Record time sz began and ended. Duration Types of movements Ongoing seizure observations Post-ictal assessment - often involves reorientation. Patient safety If the client is sitting or standing, place the client on the floor Continual assessment of the ABCs Acute Seizure Management (things to do) - Patent IV, suction, oxygen, padded side rails, pillow, and privacy. Side-lying position Suction secretions No restraints Loosen restrictive clothing Never force anything into the patient's mouth Absolutely NO tongue blade! DO NOT ATTEMPT TO STOP MOVEMENTS! Acute Seizure Management (meds) - Benzos Break the seizure may include: Lorazepam (Ativan) Diazepam (Valium) IV phenytoin (Dilantin) or fosphenytoin (Cerebyx) Status Epilepticus - Prolonged seizures that last more than 5 min or repeated seizures over course of 30 min - medical emergency! Number 1 cause is pt not taking their medication. 22% mortality rate What to do when patient is experiencing Status Epilepticus? - Establish airway ABGs IV push lorazepam, diazepam Rectal diazepam Loading dose IV phenytoin What are common Diagnostic Work Up for Status Epilepticus? - EEG CT/MRI Exclude other causes Labs Looking for Malignancy or injuries. Treatment for Status Epilepticus - Maintain therapeutic blood levels for maximal effectiveness: Teaching moment for nurses. Stress adherence. Hydantoins (e.g. phenytoin, ethotoin, fophenytoin) used to treat partial and generalized tonic-clonic seizures Do not administer warfarin with phenytoin Barbiturates (phenobarbital, primidone) often prescribed at last resort and for treatment of status epilepticus. Carbamazepine: Used in simple partial or secondary complex. Therapeutic level 8- 12 mcg/ml. >12 mcg/ml is toxic. Pregnancy and women: All AED's considered teratogenic; BC should be advised. If patient becomes pregnant, carbamazepine or levetiracetam less teratogenic. Will need more folic acid than other pregnant women. Nursing Interventions for Status Epilepticus - Look for secondary causes Evaluate most current blood level of medication, if appropriate Be aware of drug-drug/drug-food interactions Need to Stress adherence Teaching for Status Epilepticus - Driving and high reliable occupations State of FL restrictions - two years*. Rest, stress reduction, diet Ketogenic diet Medication compliance Follow-up drug levels Neurologist Medic alert tag Social service resources to assist with medication costs Evaluation of employment safety needed to decrease risks Vocational rehabilitation may be subsidized Parkison's Disease Pathophysiology - Familial, males are more affected; 3:2 male to female ratio Progressive and chronic Degradation of dopamine Substantia nigra contains dopaminergic neurons which contribute to controlled movement pattern Parkison's Disease Onset - Usually asymmetric Patient may first notice resting tremor in upper extremity, then will spread to other parts of the body in an unpredictable way Restlessness during sleep, kicking and thrashing when trying to sleep Decreased sense of smell (very gradual) Parkison's Disease Cardinal Signs - Bradykinesia Resting Tremor Rigidity Postural Instability (leaning forward and dragging feet) Parkison's Disease "Other Signs" - Pill rolling: Clenched fist with thumb moving around Reduction in dexterity Masked facies: Decreased facial expressions Sleep disturbances Autonomic dysfunction: Constipation, sweating, sexual dysfunction Bradyphrenia: Reduction of cognition—can't think as quickly or clearly Dementia: Advanced Parkinson's Disease Night time drooling (Patients may become depressed) Parkison's Diseases Physical Exam - Resting Tremor Cogwheel Rigidity (stiff) Signs reflective of bradykinesia: Decreased speed of repetitive movement Micrographia (small hand writing) Small, quiet voice with poor articulation Festinating gait Nursing Care for Parkison's Diseases - Multidisciplinary approach (SLT, PT, OT, Neurology, Dietician) Fall precautions!!! Aspiration precautions: Aspiration pneumonia is a major cause of death in Parkinson's Disease Medications on time, every time Continual nutritional assessment High-calorie, high-protein, high-fiber meal Small frequent meals I&O Screen for depression/psychosis Constipation Drug Therapy for Parkison's Disease - Multitude of drugs - often are titrated based on response. Dopaminergic (Sinemet) Dopamine agonists (ropinirole); may cause hypotension; use with caution in patients with renal or hepatic impairment; start at LOW dosage and titrate slowly upwards COMTs (entacapone) Anti-cholinergics: Benztropine---improves tremors of PD (drys everything out) MAOI-B selegiline Tyramine interaction Page 871 Nursing safety priority (Drug food interaction, no red wine, fermented food, cured meats or aged cheese) Multiple Sclerosis - Autoimmune Life-long inflammatory disease where the axonal part of the nerve impulse undergoes demyelination. Women tend to be more affected. Types of Multiple Sclerosis - Relapsing-remitting Primary Progressive Relapsing- remitting MS - Symptoms develop and then dissipate. Most common ; requires treatment during acute symptoms but generally at baseline Primary Progressive MS - Steady and gradual disability progression. Age group 15-45; average age of diagnosis is 29 in women, 31 in men. Secondary progressive Progressive-relapsing Multiple Sclerosis Assessment - Ask about vision, mobility, and sensory perception changes Symptoms are often vague Are symptoms intermittent or becoming progressively worse? Symptoms: See chart 43-1, page 889 LOPDUV: Limb weakness, Optic neuritis, Paresthesia, Diplopia, Urinary incontinence, Vertigo Physical Exam: Weakness, numbness, tingling, brisk reflexes, gait disturbances (more progressive cases), intention tremors Multiple Sclerosis (MS) Disgnosis - Symptom presentation as well as an MRI (lesions) Lumbar Puncture Muscle cramping secondary to spasticity Weakness Charcot Triad: Dysarthria, Nystagmus, Intention Tremor Dysmetria Trigeminal Neuralgia Twitching of facial muscles HEAT INTOLERANCE Fatigue and dizziness Cognitive difficulties Depression/euphoria Dementia Lumbar Puncture (MS) - Obtain consent Spinal needle injected into subarachnoid space Position patient in a fetal side-lying position Local anesthetic Three to five tubes CSF collected Post LP: Obtain VS, neuro checks, observe needle site for leakage, bedrest Nursing Care for MS (Risk for, Airway, Body, Urinary and Bowel incontinence) - Risk for infection: MS drugs alter immunity, teach patents to avoid crowds and sick people Dysarthria/dysphagia: SLP referral Fatigue Encourage rest - but encourage participation to keep the client active. Plan accordingly for activities and allow time for completion Urinary and bowel incontinence Anticholinergics: Oxybutynin UTI Surveillance - Encourage fluids Avoiding caffeinated products Nursing Care for MS (Pain, Medications, Vision Changes) - Pain Pain control, as prescribed: Baclofen, Diazepam Medications Teach how to administer parenteral forms Interferons Vision changes Eye patch for diplopia Encourage vision exams Teach the client how to scan a room (peripheral vision loss) Drug Therapy for (MS) for Acute exacerbations - with IV methylprednisolone: Iv x 2-3 days followed by po steroid taper x 3-4 months Drug Therapy for Disease progression - Interferon beta-1a (IM) or Interferon B-1b (SQ). Glatiramer (SQ): Relatively safe during pregnancy. These drugs are immunomodulators, makes patients vulnerable to infection. Must report any s/s infection to PMD immediately. Natalizumab, Fingolimod: Oral drugs but second line, used less due to adverse effects Drug Therapy for MS for various symptoms - Muscle spasticity: Baclofen, Valium Fatigue and narcolepsy: Amantadine, Modafinil, Pain (trigeminal): Phenytoin, pregabalin, carbamazepine Urinary urgency: Oxybutynin Transient Ischemic Attack (TIA) - Tried interruption in cerebral blow flow Resolve within 30-60 minutes Symptoms - blurred vision, diplopia, ataxia, extremity weakness, numbness, vertigo, aphasia and dysarthria. Warning Signs of TIA - Care is aimed at reducing risk factors for a CVA. Carotid US : May need CEA? Cardiac management (A-Fib) CT Head Reduce HTN, control diabetes, heart healthy diet, STOP SMOKING! Prescriptive therapy includes statins, anti-hypertensives, and anti-platelets(?). Stroke - Known as a brain attack where the perfusion to the brain suddenly becomes interrupted. Fifth leading cause of death worldwide Classified as either ischemic (90%) or hemorrhagic (10%) Ischemic strokes may be: - Thrombotic: Due to atherosclerotic plaques Embolic: Dislodged clot. Major risk factors include a-fib or DVT in a patient with a PFO. Stroke Patho - Ischemic stroke Most common type of stroke. Thrombotic Hx: HTN, Vascular disease Prodromal TIA Embolic Hx: AFIB, Endocarditis Hemorrhagic Hx: HTN, Vessel disorders Stroke Numbers - Accounts for 1/19 deaths in US. Ranked number 5 among cause of death in the US. 14% of patients in the hospital suffer from a stroke. They often suffer the worst prognosis. Stroke PT history - Hypertension, Hypercoagulability, Use of Oral Contraceptives, Hyperlipidemia, Diabetes, Obesity, Smokers, Genetic Factors, A-fib, Alcoholism, Illicit drug use (cocaine) Stroke Symptoms - Altered LOC, Face, Arm, Speech alterations, gait disturbances Stroke Manifest - people who are older, but always consider stroke in a patient with acute onset neurological deficits, regardless of age Stroke Risk Factors - Smoking A-Fib Age Illicit drug use (cocaine) Alcoholism Uncontrolled HTN: #1 risk factor Sedentary lifestyle Obesity Hypercoagulability Hyperlipidemia Oral contraceptives Sickle cell disease Diabetes mellitus*** Stroke Assessment - Facial dropping Arm drift Speech articulation Time Vision changes Gait disturbances Ataxia Confusion Stroke Diagnostics - CT Scan at a stroke center Symptom presentation MRI Carotid US (not immediate) Stroke Immediate Interventions - ABCs GCS Routine labs EKG Assess for hypoglycemia or hypoxia, INR Onset of symptoms NIH Stroke Scale NPO Nursing Care Stroke: Ischemic Stroke - May be a candidate for TPA therapy. Window period of time for therapy - 4.5 hours. Permissive HTN = Perfusion Notify for SBP > 180 HOB Midline, low fowlers Sooner the better! Nursing Care Stroke: TPA Therapy - IV Alteplase Contraindications Continuous VS and LOC assessment Two large bore IVs No IVFs that contain dextrose Bleeding precautions x 24 hours Increased Intracranial Pressure - Acute ischemic stroke patient at risk for increased ICP during first 72 hours after stroke onset Signs: Headache N/V Cushing's Triad Change in LOC Decreased pupil Response Seizures Abnormal Posturing Rehabilitative Nursing Care: Mobility - Hemiplegia Pressure ulcer prevention ADLs Avoid hot and cold Positioning DVT prophylaxis Rehabilitative Nursing Care: Sensory - Injury risk to flaccid extremity Homonymous hemianopsia Encourage the client to scan the room. Place objects near the client. Diplopia - eye patch Rehabilitative Nursing Care: Dysphagia - Aspiration precautions NPO until Swallow screening Thickened, as prescribed Nutritional alteration Rehabilitative Nursing Care: Speech - Aphasia Receptive - loss of comprehension Expressive - loss of production of language Global - total inability to communicate Perseveration, dysarthia Be clear and concise Use cues and gestures Avoid yes or no questions Alternative forms of communication.