NURSE-UN 1243 Adult and Elder Nursing 3 WEEK 2 Exam 1– Neuro Basics &the 3Ds
Changes in the Aging Brain
• Changes can occur, especially to the
... [Show More] prefrontal cortex and the hippocampus
• Changes also occur in neurons, neurotransmitters and blood vessels
• Damage from free radicals and inflammation increases
• Memory loss is NOT a normal part of the aging process.
• Growing evidence of the older brain having adaptive capacities
When/How to Assess Cognitive Function
When to assess:
• On admission/transfer/discharge
• Once a shift during hospitalization
• As a follow up to hospitalization within 6 weeks
• Before making an important healthcare decision
• Following changes in pharmacotherapy
• During a change in behaviour
How to assess:
• Mini mental status exam
• Mini COG
o Give patient 3 words
o Have them draw a clock w/ numbers & times
o Ask patient to repeat 3 words
Dementia
• Chronic & terminal illness
• You have a change in mental ability enough to interfere w/ daily functioning
• Must have memory loss AND another cognitive decline
o Loss of coherent speech, ability to understand spoken or written language
o Loss of ability to recognize or identify objects
o Loss of ability to execute motor activities
o Loss of ability to think abstractly, make sound judgments, plan & carry out complex tasks
Categories of dementia
• Dementia itself is not a diagnosis it is an umbrella term
o Alzheimer’s disease: amyloid plaques develop between nerve cells. 60% of
dementia diagnoses = Alzheimer’s.
o Lewy body disease: deposits of protein alpha-synuclein in the brain
o Vascular dementia: caused by damage due to major stroke or multiple minor stroke
o Frontotemporal: progressive nerve cell loss in the frontal lobes
o Normal pressure hydrocephalus: accumulation of CSF
Mild Cognitive Impairment
• Often a prodromal stage of dementia
• Independent in ADLs but with a decrease in performance
• MCI + depression = much higher likelihood of developing Alzheimer’s disease
Alzheimer’s Disease
• MOST expensive condition in the nation
• Risk factors include: age, family history, head trauma, diabetes, depression, higher education, large social networks
• Pathophysiology: development of plaques between neurons loss of connection and death of neurons
Warning Signs of Alzheimer’s
• Memory loss that disrupts daily life
• Challenges in problem solving
• Difficulty completing familiar tasks
• Confusion with time or place
• Trouble understanding visual images
• New problems w/ words
• Misplacing things
• Decreased/poor judgement
• Social withdrawal
• Changes in mood/personality
• Inability to manage a budget
Behavioural Symptoms
• Psychomotor agitation wandering, not being able to sit still
• Psychosis hallucinations, delusions
• Aggression verbal or physical
• Apathy not wanting to do anything all of a sudden
• Depression
• Sleep daytime sleepiness, sundowning (keep them awake during the day)
Stages of Alzheimer’s
1. Mild AD
• Forgetfulness
• Word finding difficulty
• Apathy
• Poor attention
• Difficulty w/ complex tasks
• Depression
• Work trouble
2. Moderate AD
• Disorientation
• Increasing memory loss
• Insomnia
• Wandering
• Speech difficulty
• Restlessness
• Difficulty w/ IADLs
3. Severe AD
• Agnosia (can’t identify things in hand)
• Apraxia (can’t move tongue to speak)
• Aggression
• Agitation
• Incontinence
• Poor ADL function
• Gait disturbances
IADLs
• Cooking
• Cleaning
• Taking medication
• Laundry
• Shopping
• Personal finances
• Communication
• Transportation
ADLs
• Eating
• Bathing
• Dressing
• Toileting
• Transferring
• Continence
Management of Alzheimer’s/Dementia
• Psychomotor agitation manage surroundings, address underlying issues, prioritize safety, should not be driving
• Psychosis evaluate meds, optimize sensory deficits
• Aggression cognitive therapies, effective communication techniques
• Apathy activity therapy
• Depression therapy, behavioural interventions, meds if indicated
• Meal time issues redirecting
• Sleep Daytime activities to realign sleep schedule
Medication Management
• KEY: start with one, start simply
• Main medications listed below but can also use the following:
o Halperidol for psychotic symptoms
o Atypical antipsychotics
o Benzodiazepines for agitation and aggression
Acetylcholinesterase Inhibitors
• Prevents breakdown of acetylcholine
• We want to titrate and increase slowly to avoid side effects (NVD, abdominal pain, jaundice, decreased HR, dizziness, headache)
• MAJOR a/e = bradycardia and heart block (d/t cholinergic crisis)
Memantine
• NMDA receptor blocker blocks excess glutamate (excitatory NT), which can reduce sx associated w/ alzheimers
• Can cause dizziness, constipation and headache
Delirium
1. Disturbances in attention: reduced ability to direct, focus, sustain, shift attention
2. Disturbances develop over a short period of time
3. Change in an additional cognitive domain memory deficit, disorientation, language disturbance, perceptual disturbance
4. Changes in 1/3 must not occur because of a coma or severe change in state of arousal
Causes of Delirium
• D = dementia, dehydration, drugs
• E = electrolyte imbalances, emotional stress, encephalopathy
• L = lung, liver, low oxygen, low vision/hearing
• I = infection, ICU
• R = Rx drugs, retention (urine/stool)
• I = injury, immobility, intake changes
• U = untreated pain, unfamiliar environment, uremia
• M = metabolic disorders
Assessing Delirium
• Confusion assessment method (CAM) (must have 1, 2 and either (3 or 4))
1. Acute onset or fluctuating course
2. Inattention
3. AND Disorganized thinking or altered level of consciousness
Nursing Management of Delirium
• Provide orientation
• Provide appropriate sensory stimulation
• Facilitate sleep
• Foster familiarity (have stuff from home)
• Maximize mobility & avoid restraints (should be up 2 days after surgery)
• Communicate clearly, provide explanations, short, simple, direct
• Reassure & educate
• Minimize invasive interventions (ie: blood draws) can increase agitation
• Consider psychotropic medications as last resort for agitation
Depression
• Most common mental disorder
• Assess using geriatric depression scale (<5 = fine, 5-10 = assess, >10 = most likely depressed)
• Assess using PHQ-2
• Symptoms
o Depressed mood
o Suicidal thoughts (high mortality, men aged 75-85 at greatest risk, often a direct relationship between depression, suicide and alcoholism)
Treatment of Depression
• SSRIs block reuptake of serotonin
• SNRIs block reuptake of serotonin and norepinephrine
• TCA related medications Ease depression by affecting naturally occurring chemical messengers (neurotransmitters), which are used to communicate
between brain cells
• CBT
• Electroconvulsion therapy
Nursing Interventions
• Safety precautions for suicide risk as per institution
• Remove/control etiologic agents
• Monitor/promote nutrition, elimination, sleep/rest patterns, physical comfort (pain control)
• Enhance physical function
• Enhance family/social/spiritual support
• Maximize autonomy/personal control/self-efficacy
• Remove catheters after surgery
• Education about medications
Neuro Basics
• Normal ICP = between 5-15 mmHg
• Earliest sign of increasing ICP is a change in consciousness other signs = papilledema, slurring of speech, delay in response, vomiting
• Late indicators of increasing ICP further decrease in LOC, Cushing’s triad, pupil changes, altered respiratory patterns, posturing
WEEK 3
Stroke
B = balance
E = eyes (blurred vision) F = facial dropping
A = arm or leg weakness S = speech difficulty
T = time to call for an ambulance!
• Stroke can either be an ischemia to part of the brain or a hemorrhage to part of the brain
• Damage will correlate to extent of stroke and part of brain affected
Non-modifiable risk factors
• Age (stroke risk doubles after the age of 55)
• Gender (more common in men, more women die)
• Ethnicity/race (higher incidence and death rate in blacks)
• Hereditary/family history
• Prior stroke/TIA
Transient Ischemic Attack
• Transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, but without acute infarction to the brain
• Symptoms typically last less than 1 hour
• No way to predict outcome
o 1/3 have no additional stroke events
o 1/3 have an additional stroke
o 1/3 have additional TIAs
Types of Stroke
• Ischemic stroke: caused by embolism, infarction and thrombosis
o Thrombotic: injury to blood vessel wall that results in the formation of a
clot, results in narrowing of blood vessel
o Embolic: occurs when an embolus lodges in and occludes a cerebral artery
• Hemorrhagic stroke: bleeding into the parenchym
o Intracerebral or intraparachymal hemmoragh
▪ Sudden onset of symptoms
▪ Poor prognosis (30 day mortality rate of 40-80%)
▪ HTN is most common cause
▪ Tends to occur during activity
o Subarachnoid space/ventricles
▪ Most often caused by cerebral aneurysm, trauma or drug abuse
▪ Majority occur in circle of willis
▪ Incidence higher in women
▪ Survivors tend to have many long term consequences
Nursing Assessment
• Focus first on cardiac, respiratory and neurological assessments
• If patient is stable, obtain the following details:
o Description of current illness (onset, duration, nature, changes)
o History of similar symptoms experienced
o Current medications
o Risk factors
o Family history
• Secondary assessment can include a comprehensive neurological examination
NIH stroke scale (must be certified to administer)
• Common mistakes include: failure to adequately stimulate patient, failure to check BG, failure to get baseline, failure to recognize subtle clues, too quick
Clinical Manifestations of Stroke
• Impairment in motor function
o Mobility
o Respiratory function
o Swallowing and speech
o Gag reflex
o Self-care abilities loss and loss of skill voluntary movement (akenesia)
o Impairment of integration of movements
o Changes in muscle tone
o Altered reflexes
o Receptive aphasia = loss of comprehension
o Expressive aphasia = loss of production of language
o Global aphasia = total loss of ability to communicate
o Dysarthia = problems with muscular control of speech
Nursing Care
Respiratory System
• Risk for atelectasis, aspiration pneumonia, airway obstruction
• May require endotracheal intubation and mechanical ventilation
• Monitor for crackles and wheezes
Cardiovascular System
• Monitor vital signs frequently
• Monitor cardiac rhythms & heart sounds for murmurs
• Calculate intake and outputs adjust fluid intake to meet demands of specific patient
• Be careful of orthostatic hypotension before ambulating the patient
• After stroke, patient is at risk for venous thromboembolism weak/paralyzed lower extremities are particularly vulnerable d/t immobility and loss of venous
tone. Keep patient moving!!
Neurological System
• Monitor closely to detect signs suggesting extension of stroke, vasospasm, recovery from stroke symptoms
Additional
• Monitor GI system for constipation
• Integumentary system for skin breakdown
• Urinary system for incontinence/bladder retraining
Nutritional Needs
• Must do a quick assessment to organize treatment for nutritional needs
• May need IV nutrition to maintain fluid and electrolyte balance
• First feeding should be done very carefully test gag reflex, pocketing, swallowing
• Feedings MUST be followed by scrupulous oral hygiene
Communication
• Decrease environmental stimuli
• Treat patient as an adult
• Speak with normal volume and tone
• Present one thought or idea at a time
• Keep it simple
• Do not rush person
• Do not pretend to understand
• Allow body contact as much as possible
• Do not push if person is tired or upset as aphasia worsens with fatigue and anxiety
Stroke Collaborative Management
• Emergent management: ABCs, prevention of stroke extension, assess level of consciousness (Glasgow Coma Scale), ICP, blood sugar, early intervention with TPA
• Endovascular intervention: TPA (must be given within 3-4.5 hours of last known normal period), only for ischemic strokes!!
• Medications: can also give aspirin, antihypertensives, steroids, anti-epileptics
• Glasgow coma scale (3 = deep coma/brain dead, 15 = fully awake)
Intracranial Pressure
• Normal ICP is between 5-15 mm Hg
• The earliest sign of a change in ICP is a change in level of consciousness
• Early indicators in a change of ICP
o Papilledema
o Slurred speech
o Delay in response
o Vomiting
• Late indicators in a change of ICP
o Further decrease in LOC
o Cushing’s triad (increase SBP with widening pulse pressure, bradycardia, altered respirations)
o Pupil changes
o Altered respiratory patterns
o Posturing
Parkinson’s Disease
• Complex interplay between environmental factors and family history
• Characterized by
o Bradykinesia
o Rigidity (cogwheel rigidity)
o Tremor at rest
o Gait changes (postural instability disturbed gait and leaning forward)
• Idiopathic PD, no identifiable cause & insidious onset
• Acquired PD, caused by infection, drug toxicity (if d/t drug toxicity it progresses rapidly), trauma
• Dx: no specific disease markers, sometimes dx by how well the pt responds to medication MRI/CT can be used to rule out other conditions to narrow down to parkinsons
Pathophysiology
• Lack of dopamine (DA)
• Degeneration of dopamine producing neurons in the substantia nigra of the midbrain disruption of dopamine-acetylcholine in the basal ganglia disrupts normal functioning of extrapyramidal motor system
PD Assessment and Diagnosis
• Neuropsych sx: depression, personality changes, psychosis, hallucinations
• Autonomic dysfunction: orthostatic hypotension, diaphoresis, drooling, weight loss, urinary sx
• Neuromuscular: camptocormia, festination, gait freezing, hyphonia, monotonic speech, festinating speech, dysphagia, hypomimia, micrographia, akathisia
• Sleep disturbances: vivid dreams, insomnia, daytime drowsiness
PD Collaborative MGMT
• Levodopa
o Effective but benefits decrease w/ time
o Long term use carries risk of dyskinesias
o Can be used w/ drugs to assist such as: carbidopa, COMT inhibitors, MOA-B inhibitors
• Dopamine receptor agonists
o Less effective
o Less likely to cause dyskinesias
o Can cause troubling side effects
• Surgical/electrical tx
• Diet: monitor ability of patient to chew and swallow, collaborate with dietician, cut food into small bite sized pieces, eat 6 small meals a day, limit protein intake
to evening meal
• Exercise: collaborate w/ PT to develop safe exercise intervention
• Psychosocial: assess for depression, anxiety and insomnia
• Daily living: allow pt to perform ADLs (toileting, transferring, ambulating, bathing, continence, eating)
Normal Pressure Hydrocephalus
• Accumulation of CSF causing the ventricle of the brain to enlarge
• Unknown cause associated w/ gait disturbance, dementia, urinary incontinence
• Tx: shunt
WEEK 4 – Neurological & vascular problems
Why are older adults at an increased risk of hematomas?
1. Dura matter becomes more adherent, brain weight decreases, reaction times slow
2. Many adults take anticoagulants/aspirin
Primary Head Injury vs Secondary Head Injury
Primary
• Occurs on IMPACT, is a direct result of the impact
• Ex: contusions, hematomas, shearing injuries, diffuse white matter injuries, brain lacerations
Secondary
• Follows the original event and further contributes to the brain injury
• Ex: hypoxia, Hypercapnia, systemic hypertension, intracranial hypertension, ischemia, age, PMH
• What can help? Hypertonic saline aids in preventing secondary injury
Concussion
• Sudden transient mechanical head injury causes disruption of neural activity and a change in LOC
• Post concussion syndrome: persistent headache, lethargy, behaviour changes, changes in intellectual ability, short attention span, decreased short term memory
Contusion
• Bruising of the brain w/ a focal area
• Associated w/ a closed-head injury
• Can cause hemorrhage, necrosis, edema, infection
• Monitor for seizures
Diffuse Axonal Injury
• Widespread axonal injury that results from the brain rapidly shifting inside of the skull
• The axons are sheared permanent death of the brain cell
• Causes decreased level of consciousness, increased intracranial pressure, global cerebral edema
Linear Skull Fracture
• Minor traumatic injury
• Diagnosed by CT
• Non-life threatening, will heal on its own
Depressed Skull Fracture
• May be visible and palpable, can tear meninges of brain and extend into the tissue
• Requires surgical repair of fracture and meninges
• May need to evacuate the hematoma
• Nursing focus? Pain management of neurological assessment
Open/Compound Skull Fracture
• Depressed skull fracture with scalp laceration
• Risk of infection!!
• Nursing focus should be on pain management, neurological assessment and preventing infection
Basilar Skull Fracture
• Fracture of one of the bones that make up the skull
• Assessment findings will probably include:
o Periorbital ecchymosis
o Mastoid ecchymosis
o Facial nerve paralysis
o Otorrhea leakage of CSF from ear
o Rinnorhea leakage of CSF from nose
Nursing/Medical Intervention
• Determine if glucose is present in leakage. You will see the halo/ring sing if CSF is present (red yellow).
• Allow CSF to drain and dura to heal on its own. If it does not heal in 1-2 weeks it
may require surgical intervention.
• Nursing interventions:
o Neurological assessment
o Pain assessment
o Monitor for infection
o Change dressings with aseptic technique
o Use cotton to absorb CSF leak
o Raise HOB
• Do not use nasograstric tube for basilar skull fracture
Closed Head Injuries
• Cerebral hematoma is an accumulation of blood in the skull. It occurs as result of an injury to a cerebral vein or artery.
Subdural Hematoma ACUTE
• Occurs <48 hours of an injury
• Often associated with sudden deceleration or in patients on anticoagulants who have a contusion
• Sx: drowsiness, headache, confusion, slowed thinking, agitation
SUBACUTE
• 48 hrs-2 weeks post-injurt
• Neurological deterioration does not occur immediately
CHRONIC
• Occurs more than 2 weeks post-injury
• Often results from a low-impact injury
• Sx: headache, lethargy, vomiting, seizures, pupil changes & hemiparesis
Management
• Drain the hematoma
• Frequently reassess LOC (nursing intervention)
Complications of a Closed Head Injury
• Diabetes insipidus: causes improper water balance pressure on pituitary causes loss of ADH secretion large amounts of dilute urine is excreted. GIVE VASOPRESSIN.
• SIADH: excess secretions of ADH increased ICP. Restrict fluids, monitor I&Os, neurological assessments key.
• Herniation
• Seizures
Pupillary Assessment
• Pupils equal and react normally
• Pupils react to light
• One pupil dilates compression of cranial nerve III
• Bilateral dilated, fixed pupils ominous signs
• Bilateral pinpoint pupils pons damage or drugs
Decorticate Posturing
• Sign of severe brain injury
• Damage to midbrain
Decebrate Posturing
• Sign of very severe brain injury
Decorticate & Decebrate Posturing
Opisthonic Posturing
Additional Diagnostic Studies
• CT scan: best way to diagnose craniocerebral trauma
• MRI, PET
• Transcranial Doppler
• X-Ray
• Glasgow Coma Scale (3-8, severe/9-12, moderate/13-15, mild)
Emergency Treatment
• <8 = intubate
• Patent airway
• Stabilizer cervical spine
• Maintain patient warmth
• Monitor
• Anticipate intubation
• Assume neck injury
• Give fluids cautiously
• Remove clothing
• Obtain IV access
• Control bleeding
Nursing Diagnosis/Planning
• Risk for ineffective cerebral tissue perfusion
• Hyperthermia
• Impaired physical mobility
• Anxiety
• Increased ICP
Nursing Interventions
• Eye drops, compresses, patch
• Hyperthermia: goal 36-37 degrees
• Prevent shivering
• Elevate HOB
• Loose collection pad under nose/over ear
• NO sneezing, blowing nose
• NO NG tube
• NO nasotracheal suctioning
Epilepsy
• Seizures: cluster of nerve cells in the brain signal abnormally transient, uncontrolled electrical discharge of neurons in the brain
o Possible causes include: alcohol withdrawal, acidosis, electrolyte imbalance, hypoglycemia, hypoxemia, dehydration or water intoxication
• Epilepsy: a person has had at least two seizures that were not caused by a known medical condition (UNPROVOKED)
o Secondary/provoked seizures may occur d/t: brain tumour, metabolic disorder, alcohol withdrawal, electrolyte imbalance, high fever, stroke, head injury, substance use, heart disease
Four Stages of a Seizure
1. Prodromal
2. Aural
3. Ictal
4. Post-ictal
Types of Seizure
FOCAL ONSET
• Focal-aware seizure: used to be called partial seizure, the person experiencing the seizure is conscious and will know something is happening/remember the seizure
• Focal-impaired awareness seizure: used to be called complex partial seizure
consciousness affected, may be confused, can hear but not fully understand
GENERALIZED ONSET
• Affects both sides of the brain at once and happens without warning
• Tonic-clonic seizure: classic seizure jerk motions
• Atonic seizure: person goes flaccid falls toward
• Tonic seizure: muscles become stiff fall backwards
ADDITIONAL TYPES
• Myoclonic: muscle jerks, not associated w/ epilepsy people have them as they fall asleep
• Absence seizures: used to be called petite-mal seizures, person becomes blank and unresponsive for a few seconds
• Unknown onset: occurs when the beginning of the seizure is unknown
• Non motor seizure: behavioural arrest
Seizure Assessments/Interventions
• Collect data on history of seizures/current seizure
o Important to note which body part the seizure started with
o Changes in pupil size or eye deviation
o Changes in LOC
o Cyanosis, apnea, salivation
o Incontinence
o Tongue or lip biting
o When seizure ended
• Reinforce medication compliance
• Emphasize safety issues
o Place patient on side
o Use padded bed rails
o Pillow under head
o Bed in lowest position
o Side rails up
o Stay with patient
o Monitor for status epilepticus can give Ativan/Diazepam
Seizure Medications
• Work to decrease start or decrease spread
• AEDs are the most commonly used drugs gabapentin, keppra, tiagabine, topirmate, lamotrigine
Seizure Complications
• Status epilepticus: state of continuous seizure activity (>5 minutes)
o Causes brain to use more energy than supplied
o Permanent brain damage can result
Vascular Disorders
HTN Management
• Restrict sodium to <1500 mg/d or 1000 mg/d
• Reduce body weight
• Reduce alcohol intake (1 drink per day for women, 2 drinks per day for men)
• Exercise
• Decrease stress levels
• Don’t smoke
Peripheral Arterial Disease
• Progressive thickening of the arteries with fatty deposits causes degeneration of arteries
• Femoral-popliteal artery is most common site in non-diabetics
• In diabetics, most common site is distal arteries below the knees
• Sx: intermittent claudation, decreased/absent peripheral pulses, loss of hair on arms, feet, legs, ulceration or gangrene of toes and feet, nails thickened/brittle
1. Stage 1 = asymptomatic
2. Stage 2 = claudation
3. Stage 3 = rest pain
4. Stage 4 = necrosis, gangrene, ulcers
Ankle-Brachial Index
• Divide ankle SBP/brachial SBP
• 1-1.3 = normal
• >0.90 = venous disease
• <0.90 = arterial disease
• 0.90-0.71 = mild arterial disease
• 0.70-0.40 = moderate arterial disease
• <0.40 = severe arterial disease
Venous Stasis Ulcer
• Incompetent valves of deep veins, usually caused by prolonged HTN
• Brown, leathery skin
• Ulcers develop at the ankle, above the malleolus
• Elevate extremities, extrinsic compression, wound care, observe for infection [Show Less]