Rehab Quiz One Review!

Spinal cord injury & complete transsection of cord

Complete spinal cord transection

1. Quadriplegia with injuries of the cervical spinal cord

2. Paraplegia with injuries of the thoracic spinal cord

Muscle flaccidity

Loss of all reflexes below the level of injury

Loss of pain, temperature, touch, pressure, and proprioception below the level of injury

Pain at the site of injury caused by a zone of hyperesthesia above the injury

Atonic bladder and bowel

Paralytic ileus with distention

Loss of vasomotor tone in the lower body parts; low and unstable blood pressure

Loss of perspiration below the level of injury

Loss or extreme depression of genital reflexes such as penile erection and

bulbocavernous reflex

Dry and pale skin; possible ulceration over bony prominences

Respiratory impairment

Complete: All tracts in the spinal cord completely disrupted; all cord-mediated functions

below the transection are completely and permanently lost

Know autonomic disreflexia

Observe the patient with an upper SCI (above the level of T6) for signs of autonomic dysreflexia

(hyperreflexia). Although it does not occur frequently, autonomic dysreflexia is an excessive,

uncontrolled sympathetic output. It is characterized by severe hypertension, bradycardia, severe

headache, nasal stuffiness, and flushing (Chart 45-10). The cause of this syndrome is a noxious

stimulus—usually a distended bladder or constipation. This is a neurologic emergency and must

be promptly treated to prevent a hypertensive stroke! Chart 45-11 lists emergency care for

autonomic dysreflexia.

Cervical spinal cord injury (nursing mgmt, priorities)… several questions here

ABCs. Keep the distracters in mind

Assessing the ABCs (airway, breathing, circulation) is the priority for any trauma patient.

Therefore the first priority for the patient with an SCI is to assess the patient's airway,

breathing pattern, and circulation status. The airway may be compromised because of

foreign body obstruction from the tongue or teeth due to facial trauma, injury to the

larynx, or mandibular (jaw) fracture (Harris & Sethi, 2006). After an airway is

established, assess the patient's breathing pattern. The patient with a cervical SCI is at

high risk for respiratory compromise because the cervical spinal nerves (C3-5) innervate

the phrenic nerve, which controls the diaphragm. A significant head injury,

pneumothorax (air in the chest cavity), hemothorax (blood in the chest cavity), and/or

fractured ribs may also cause respiratory distress. Injuries to the occiput (back of the

head) and C2 are more likely to occur in the older adult who fell from a low height.

Endotracheal intubation with mechanical ventilation may be necessary to prevent

respiratory arrest.

Assess for indications of intra-abdominal hemorrhage or hemorrhage or bleeding around

fracture sites. Indicators of hemorrhage include hypotension and tachycardia with a weak

and thready pulse.

Use the Glasgow Coma Scale (see Chapter 43) or other agency-approved assessment tool

to assess the patient's level of consciousness (LOC). Cognitive impairment as a result of

an associated traumatic brain injury (TBI) or substance abuse is common in patients with

traumatic SCIs. Perform a detailed assessment of the patient's motor and sensory status to

assist in determining the level of injury and serve as baseline data for future comparison.

The level of injury is the lowest neurologic segment with intact or normal motor and

sensory function. Tetraplegia (also called quadriplegia) (paralysis) and quadriparesis

(weakness) involve all four extremities, as seen with cervical cord and upper thoracic

injury. Paraplegia (paralysis) and paraparesis (weakness) involve only the lower

extremities, as seen in lower thoracic and lumbosacral injuries or lesions.

Spinal shock, also called spinal shock syndrome, occurs immediately as a concussion

response to the injury. The patient has flaccid paralysis and loss of reflex activity below

the level of the lesion. It often lasts less than 48 hours but may continue for several weeks

(McCance & Huether, 2006). Muscle spasticity begins in patients with cervical or high

thoracic injuries when spinal shock is resolved.

Assessment of Sensory and Motor Ability. Sensation is carried from the peripheral nerves to the spinal cord and up to the cerebral

cortex through several specific tracts. Injury to the spinal cord may prevent those

impulses from reaching the brain. To test sensory abilities, ask the patient to close his or

her eyes. Touch the skin with a clean safety pin or cotton-tipped applicator, and ask

whether he or she can feel the pinprick or light touch. Compare bilateral responses.

Follow the sensory distribution of the skin dermatomes (see Fig. 43-5 in Chapter 43),

with the examination beginning in the area of reported loss of sensation and ending where

sensation becomes normal. For example, sensation of the top of the foot and calf of the

leg is spinal skin segment (dermatome) levels L3, L4, and L5. The area at the level of the

umbilicus is T10, the clavicle (collarbone) is C3 or C4, and finger sensation is C7 and

C8. The patient may report a complete sensory loss, hypoesthesia (decreased sensation),

or hyperesthesia (increased sensation).

The patient's proprioceptive (position sense) function may be assessed. Request that the

patient again close his or her eyes. Next move one of his or her fingers or toes up or

down. Ask the patient to identify the position of the digits.

In addition to performing a routine motor evaluation of the patient, selected muscles are

tested in a more systematic fashion (Chart 45-8). Many scales are available to measure

motor function. The American Spinal Injury Association (ASIA) recommends a five-

point grading scale, with 0 being no movement and 5 being normal strength (see Table

52-2 in Chapter 52). Ask the patient to flex and extend the elbows, elevate both arms off

the bed, flex and extend the wrists and fingers, and touch each finger to the thumb.

Patients with spinal injuries at the fifth or sixth cervical vertebra often can flex but not

extend their arms. Observe the patient's ability to move the lower extremities. Ask him or

her to wiggle the toes, flex and extend the feet and knees, and move one or both hips.

The advanced practice nurse or health care provider may also test deep tendon reflexes

(DTRs), including the biceps (C5), triceps (C7), patella (L3), and ankle (S1). It is not

unusual for these reflexes, as well as all movement or sensation, to be absent immediately

after the injury because of spinal shock. After shock has resolved, the reflexes may return

if the lesion is incomplete or involves upper motor neurons.

BEST PRACTICE FOR PATIENT SAFETY & QUALITY CARE

Assessing Motor Function in the Patient with a Spinal Cord

Injury • To assess C4-5, apply downward pressure while the patient shrugs his or her

shoulders upward.

• To assess C5-6, apply resistance while the patient pulls up his or her arms.

• To assess C7, apply resistance while the patient straightens his or her flexed arms.

• To assess C8, make sure the patient is able to grasp an object and form a fist.

• To assess L2-4, apply resistance while the patient lifts his or her legs from the

bed.

• To assess L5, apply resistance while the patient dorsiflexes his or her feet.

• To assess S1, apply resistance while the patient plantar flexes his or her feet.

Cardiovascular and Respiratory Assessment. Cardiovascular dysfunction results from disruption of sympathetic fibers of the

autonomic nervous system (ANS), especially if the injury is above the sixth thoracic

vertebra. Bradycardia, hypotension, and hypothermia occur because of loss of

sympathetic input. These changes may lead to cardiac dysrhythmias. A systolic blood

pressure below 90 mm Hg requires treatment because lack of perfusion to the spinal cord

could worsen the patient's condition. In addition, the lack of sympathetic or hypothalamic

control causes the patient to lose thermoregulatory functions. As a result, the body tends

to assume the temperature of the environment and attempts to compensate by increasing

extracellular fluid.

A patient with a cervical SCI is at risk for respiratory problems resulting from

immobility or from an interruption of spinal innervation to the respiratory muscles. In

collaboration with the respiratory therapist (RT), if available, perform a complete

respiratory assessment, including pulse oximetry for arterial oxygen saturation. The RT

should also evaluate vital capacity and minute volume as part of the assessment. These

tests are repeated as the patient's clinical status requires.

(Ignatavicius, Donna D.. Medical-Surgical Nursing: Patient-Centered Collaborative

Care, Single Volume, 6th Edition. W.B. Saunders Company, 022009. 48.5.1.5.1.2.1).

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Seizure patients. What do you do & not do

Precautions are taken to prevent the patient from injury if a seizure occurs. Specific

seizure precautions vary depending on health care agency policy. Be sure that oxygen

and suctioning equipment with an airway are readily available. If the patient does not

have an IV access, insert a saline lock, especially for those patients who are at significant

risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV

drug therapy must be given to stop the seizure.

Siderails should be in the “up” position at all times. Siderails are rarely the source of

significant injury, and the effectiveness of the use of padded siderails to maintain safety

is debatable. Padded siderails may embarrass the patient and the family. Follow agency

policy about the use of siderails because they are now classified as a restraint device.

Other methods to protect the patient, such as placing a mattress on the floor, may be used

instead of siderails.

Padded tongue blades do not belong at the bedside and should NEVER be inserted into

the patient's mouth because the jaw may clench down as soon as the seizure begins!

Forcing a tongue blade or airway into the mouth is more likely to chip the teeth and

increase the risk of aspirating tooth fragments than prevent the patient from biting the

tongue. Furthermore, improper placement of a padded tongue blade can obstruct the

airway.

One med question… she is hoping to delete… one on heparin she wants to

delete.

Couple drug calc questions….. simple

Risk factors assoc with seizures

The actions taken during a seizure should be appropriate for the type of seizure (Chart 44-5). For

example, for a simple partial seizure, observe the patient and document the time that the seizure

lasted. Redirect the patient's attention away from an activity that could cause injury. Turn the

patient on the side during a generalized tonic-clonic or complex partial seizure because he or she

may lose consciousness. If possible, turn the patient's head to the side to prevent aspiration and

allow secretions to drain. Remove any objects that might injure the patient.

BEST PRACTICE FOR PATIENT SAFETY & QUALITY CARE

Care of the Patient During a Tonic-Clonic or Complete Partial Seizure

• Protect the patient from injury.

• Do not force anything into the patient's mouth.

• Turn the patient to the side to keep the airway clear.

• Loosen any restrictive clothing the patient is wearing.

• Maintain the patient's airway and suction as needed.

• Do not restrain or try to stop the patient's movement; guide movements if necessary.

• Record the time the seizure began and ended.

• At the completion of the seizure:

• Take the patient's vital signs.

• Perform neurologic checks.

• Keep the patient on his or her side.

• Allow the patient to rest.

• Document the seizure (see Chart 44-6).

It is not unusual for the patient to become cyanotic during a generalized tonic-clonic seizure. The

cyanosis is generally self-limiting, and no treatment is needed. Some health care providers prefer

to give the high-risk patient (e.g., older adult, critically ill or debilitated patient) oxygen by nasal

cannula or facemask during the postictal phase. He or she is not restrained because this may

cause injury and may worsen the situation, causing more seizure activity. For any type of

seizure, carefully observe the seizure and document assessment findings (Chart 44-6).

Emergency Care:

Acute Seizure and Status Epilepticus Management. Seizures occurring in greater intensity,

number, or length than the patient's usual seizures are considered acute. They may also appear in

clusters that are different from the patient's typical seizure pattern. Treatment with lorazepam

(Ativan, Apo-Lorazepam ) or diazepam (Valium, Meval , Vivol, Diastat [rectal

diazepam gel]) may be given to stop the clusters to prevent the development of status epilepticus.

IV phenytoin (Dilantin) or fosphenytoin (Cerebyx) may be added.

Status epilepticus is a medical emergency and is a prolonged seizure lasting longer than 5

minutes or repeated seizures over the course of 30 minutes. It is a potential complication of all

types of seizures. Seizures lasting longer than 10 minutes can cause death! Common causes of

status epilepticus include:

• Sudden withdrawal from antiepileptic drugs

• Infections

• Acute alcohol or drug withdrawal

• Head trauma

• Cerebral edema

• Metabolic disturbances

Convulsive status epilepticus must be treated promptly and aggressively! Establish an airway

and notify the health care provider immediately if this problem occurs! Establishing an airway is

the priority for this patient's care. Intubation by an anesthesia provider or respiratory therapist

(RT) may be necessary. Administer oxygen as indicated by the patient's condition. If not already

in place, establish IV access with a large-bore catheter, and start 0.9% sodium chloride. The

patient is usually placed in the intensive care unit for continuous monitoring and management.

Ross stages of grief

Denial — "I feel fine."; "This can't be happening, not to me."

Denial is usually only a temporary defense for the individual. This feeling is generally

replaced with heightened awareness of situations and individuals that will be left behind

after death.[1]

Anger — "Why me? It's not fair!"; "How can this happen to me?"; "Who is to blame?"

Once in the second stage, the individual recognizes that denial cannot continue. Because

of anger, the person is very difficult to care for due to misplaced feelings of rage and

envy. Any individual that symbolizes life or energy is subject to projected resentment and

jealousy.[1]

Bargaining — "Just let me live to see my children graduate."; "I'll do anything for a few

more years."; "I will give my life savings if..."

The third stage involves the hope that the individual can somehow postpone or delay

death. Usually, the negotiation for an extended life is made with a higher power in

exchange for a reformed lifestyle. Psychologically, the person is saying, "I understand I

will die, but if I could just have more time..."[1]

Depression — "I'm so sad, why bother with anything?"; "I'm going to die . . . What's the

point?"; "I miss my loved one, why go on?"

During the fourth stage, the dying person begins to understand the certainty of death.

Because of this, the individual may become silent, refuse visitors and spend much of the

time crying and grieving. This process allows the dying person to disconnect oneself

from things of love and affection. It is not recommended to attempt to cheer up an

individual who is in this stage. It is an important time for grieving that must be

processed.[1]

Acceptance — "It's going to be okay."; "I can't fight it, I may as well prepare for it."

This final stage comes with peace and understanding of the death that is approaching.

Generally, the person in the fifth stage will want to be left alone. Additionally, feelings

and physical pain may be non-existent. This stage has also been described as the end of

the dying struggle.[1]

Types of seizures & symptoms assoc w/ each: generalized, partial & absence

The International Classification of Epileptic Seizures recognizes three broad categories of

seizure disorders: generalized seizures, partial seizures, and unclassified seizures.

Generalized Seizures Six types of generalized seizures may occur and involve both cerebral hemispheres. The

tonic-clonic seizure lasting 2 to 5 minutes begins with a tonic phase that causes

stiffening or rigidity of the muscles, particularly of the arms and legs, and immediate loss

of consciousness. Clonic or rhythmic jerking of all extremities follows. The patient may

bite his or her tongue and may become incontinent of urine or feces. Fatigue, acute

confusion, and lethargy may last up to an hour after the seizure.

Occasionally, only tonic or clonic movement may occur. A tonic seizure is an abrupt

increase in muscle tone, loss of consciousness, and autonomic changes lasting from 30

seconds to several minutes. The clonic seizure lasts several minutes and causes muscle

contraction and relaxation.

The absence seizure is more common in children and tends to run in families. It consists

of brief (often just seconds) periods of loss of consciousness and blank staring as though

the person is daydreaming. The patient's eyes may flutter and automatisms (involuntary

behaviors) such as lip smacking and picking at clothes may also occur. He or she is not

aware of these behaviors. The patient returns to baseline immediately after the seizure.

Left undiagnosed or untreated, the seizures may occur frequently throughout the day,

interfering with school or other daily activity.

The myoclonic seizure causes a brief jerking or stiffening of the extremities that may

occur singly or in groups. Lasting for just a few seconds, the contractions may be

symmetric (both sides) or asymmetric (one side).

In an atonic (akinetic) seizure, the patient has a sudden loss of muscle tone, lasting for

seconds, followed by postictal (after the seizure) confusion. In most cases, these seizures

cause the patient to fall, which may result in injury. This type of seizure tends to be most

resistant to drug therapy.

Partial Seizures Partial seizures, also called focal or local seizures, begin in a part of one cerebral

hemisphere. They are further subdivided into two main classes: complex partial seizures

and simple partial seizures. In addition, some partial seizures can become generalized

tonic-clonic, tonic, or clonic seizures. Partial seizures are most often seen in adults and

generally are less responsive to medical treatment when compared with other types.

Complex partial seizures may cause loss of consciousness (syncope), or “black out,” for

1 to 3 minutes. Characteristic automatisms may occur as in absence seizures. The patient

is unaware of the environment and may wander at the start of the seizure. In the period

after the seizure, he or she may have amnesia (loss of memory). Because the area of the

brain most often involved in this type of epilepsy is the temporal lobe, complex partial

seizures are often called psychomotor seizures or temporal lobe seizures.

The patient with a simple partial seizure remains conscious throughout the episode.

He or she often reports an aura (unusual sensation) before the seizure takes place. This

may consist of a “déjà vu” (already seen) phenomenon, perception of an offensive

smell, or sudden onset of pain. During the seizure, the patient may have one-sided

movement of an extremity, experience unusual sensations, or have autonomic

symptoms. Autonomic changes include a change in heart rate, skin flushing, and

epigastric discomfort.

Unclassified, or idiopathic, seizures account for about half of all seizure activity. They

occur for no known reason and do not fit into the generalized or partial classifications.

Priorities in cervical spine injuries

The highest priority intervention is to establish a patent airway. Even minutes without an

adequate oxygen supply in humans can lead to cerebral injury that can progress to anoxic

brain death. The airway is cleared of any secretions or debris either with a suction

catheter or manually if necessary. The cervical spine is protected in any trauma patient

with the potential for spinal injury by manually aligning the neck in a neutral, in-line

position and using a jaw-thrust maneuver when establishing an airway. Supplemental

oxygen is required for all patients who require resuscitation. In general, a non-rebreather

mask is best for the spontaneously breathing patient. Bag-valve-mask (BVM) ventilation

with the appropriate airway adjunct and a 100% oxygen source is indicated for the person

who needs ventilatory assistance during resuscitation. A patient with significantly

impaired consciousness requires a definitive airway such as an endotracheal tube

(American College of Surgeons, 2004) (Fig. 10-3). After endotracheal intubation, a

mechanical ventilator is employed. Initially, oxygen in high concentration (FIO2 100%) is

administered; lower concentrations may be requested after the patient's condition has

improved.

After the airway is successfully secured, breathing becomes the next priority in the

primary survey. This assessment determines whether or not ventilatory efforts are

effective—not only whether or not the patient is breathing. The focus is on auscultation of

breath sounds and evaluation of chest expansion, respiratory effort, and any evidence of

chest wall trauma or physical abnormalities. Both apneic patients and those with poor

ventilatory effort need BVM ventilation for support until endotracheal intubation is

performed and a mechanical ventilator is used. If cardiopulmonary resuscitation (CPR)

becomes necessary, the mechanical ventilator must be disconnected and the patient

manually ventilated with a BVM device. Lung compliance can be assessed through

sensing the degree of difficulty in ventilating the patient with the BVM.

Another lifesaving intervention that may be performed in this phase is chest

decompression, either with a needle or chest tube to vent trapped air. The main indication

for chest decompression is clinical evidence of a tension pneumothorax, which can pose a

critical threat to both breathing and circulation. Symptoms include decreased to absent

breath sounds over the affected side, respiratory distress, hypotension, jugular vein

distention, and tracheal deviation (late). If unrelieved, a tension pneumothorax causes

mediastinal shift, cardiovascular collapse, and death. Causes of tension pneumothorax

include barotrauma from BVM ventilation or other positive-pressure ventilation, blunt or

penetrating chest trauma, and expansion of a simple pneumothorax.

When effective ventilation is ensured, the priority shifts to circulation. The adequacy of

heart rate, blood pressure, and overall perfusion becomes the focus of the assessment.

Common threats to circulation include cardiac arrest, myocardial dysfunction, and

hemorrhage leading to a shock state. Interventions are targeted at restoring effective

circulation through cardiopulmonary resuscitation, hemorrhage control, IV vascular

access with fluid and blood administration as necessary, and drug therapy. External

hemorrhage is usually quite obvious and best controlled with firm, direct pressure on the

bleeding site with thick, dry dressing material (Laskowski-Jones, 2006c). This method is

effective in decreasing blood flow for the majority of wounds—even those caused by

amputations (Laskowski-Jones, 2006b). Thus tourniquets that occlude arterial blood flow

distal to the injury should not be used to control bleeding unless hemorrhage is so severe

that the risk to limb viability is justified to save a life. Internal hemorrhage is a more

hidden complication that must be suspected in injured patients or those who present in a

shock state.

Bells palsy vs. trigeminal neuralgia (know difference)

Bell’s palsy is a unilateral paralysis of the facial nerve, thought to result from trauma to the

nerve, compression of the nerve, or infection, of which herpes simplex virus is thought to be

the most common. Any or all branches of the nerve may be affected. The person may not be

able to close an eye or control salivation on the affected side. It usually resolves over weeks

but can leave some permanent damage, including decreased taste and hypersensitivity to

noise on the affected side. (CN 7)

Trigeminal neuralgia is a neurologic condition of the trigeminal facial nerve (CN 5),

characterized by paroxysms of flashing, stablike pain radiating along the course of a branch

of the nerve from the angle of the jaw. It is caused by degeneration of the nerve or by

pressure on it. Any or all of the three branches of the nerve may be affected. Neuralgia of the

first branch results in pain around the eyes and over the forehead; of the second branch, in

pain in the upper lip, nose, and cheek; of the third branch, in pain on the side of the tongue

and the lower lip. The momentary bursts of pain recur in clusters lasting many seconds.

Paroxysmal episodes of the pains may last for hours.

Chronic illness & disease: changes to increase our life expectancy… impacts.

Major s/s of myasthenia gravis

an abnormal condition characterized by chronic fatigability and muscle weakness,

especially in the face and throat, as a result of a defect in the conduction of nerve

impulses at the neuromuscular junction.

observations

Muscular fatigability in myasthenia gravis is caused by the inability of receptors at the

myoneural junction to depolarize because of a deficiency of acetylcholine; hence the

diagnosis may be made by administering an anticholinesterase drug and observing

improved muscle strength and stamina. The onset of symptoms is usually gradual, with

ptosis of the upper eyelids, diplopia, and weakness of the facial muscles. The weakness

may then extend to other muscles innervated by the cranial nerves, particularly the

respiratory muscles. Muscular exertion aggravates the symptoms, which typically vary

over the course of the day. The disease occurs in younger women more often than in

older women and in men over 60 years of age more often than in younger men.

interventions

Anticholinesterase drugs are given. The edrophonium test is used to determine the

optimal maintenance dose. Neostigmine or pyridostigmine is the drug most often used.

nursing considerations

Physical activity is restricted and bed rest encouraged. Anticholinesterase drugs are

usually administered before meals, and the patient is monitored for toxic side effects.

Myasthenic crisis may require emergency respiratory assistance. The patient's diet may

have to be adjusted if the ability to chew and swallow is affected.

(Mosby. Mosby's Dictionary of Medicine, Nursing & Health Professions, 8th Edition.

Mosby, 122008.).

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What is rehab nursing all about

Difference between primary & secondary prevention (cancer)

Cultural competence: how do we get health care providers culturally

competent.

s/s of diff headaches (migraines, cluster, etc.

Cluster headaches: a condition characterized by attacks of intense unilateral pain, occurring

most often over the eye and forehead. It is accompanied by flushing and watering of the eyes and

nose. Cluster headaches are more common in males and are associated with alcohol use. The

attacks occur in groups with a duration of several hours.

Migraines: a recurring headache characterized by unilateral onset, severe throbbing pain,

photophobia, phonophobia, and autonomic disturbances during the acute phase, which may last

for hours or days. The disorder occurs more frequently in women than in men, and a

predisposition to migraine may be inherited. The exact mechanism responsible for the disorder is

not known, but the head pain may be related to dilation of extracranial blood vessels, which may

be the result of chemical changes that cause spasms of intracranial vessels. Allergic reactions,

excess carbohydrates, iodine-rich foods, alcohol, bright lights, or loud noises may trigger attacks,

which often occur during a period of relaxation after physical or psychic stress.

observations

An impending attack may be heralded by visual disturbances, such as aura, flashing lights

or wavy lines, or by a strange taste or odor, numbness, tingling, vertigo, tinnitus, or a

feeling that part of the body is distorted in size or shape. The acute phase may be

accompanied by nausea, vomiting, chills, polyuria, sweating, facial edema, irritability, and

extreme fatigue. After an attack the individual often has dull head and neck pains and a

great need for sleep.

interventions

Ergotamine tartrate preparations that constrict cranial arteries can usually prevent the

headache from developing if administered early in the onset via injection, suppository,

tablet, or nasal spray. Ergotamine tartrate is also available in combination with other drugs,

such as caffeine, phenobarbital, and belladonna. Migraine patients unable to tolerate ergot

preparations may use other analgesics, including acetaminophen, NSAIDs, triptan, and

propoxyphene. If headaches happen frequently, a prophylactic medication may be taken

daily.

Tension headache: a pain that affects the head as the result of overwork or emotional strain and

that involves tension in the muscles of the neck, face, and shoulder.

focus a little extra on migraines

parkinsons disease (diagnostically, what does it look like, etiology)

a slowly progressive degenerative neurologic disorder characterized by resting tremor,

pill rolling of the fingers, a masklike facies, shuffling gait, forward flexion of the trunk,

loss of postural reflexes, and muscle rigidity and weakness. It is usually an idiopathic

disease of people over 60 years of age; it may occur in younger people, however,

especially after acute encephalitis or carbon monoxide or metallic poisoning, particularly

by reserpine or phenothiazine drugs. Typical pathologic changes are destruction of

neurons in basal ganglia; loss of pigmented cells in the substantia nigra; and depletion of

dopamine in the caudate nucleus, putamen, and pallidum, structures in the neostriatum

that normally contain high levels of the neurotransmitter dopamine. Signs and symptoms

of Parkinson's disease, which include resting tremor, bradykinesias, drooling, increased

appetite, intolerance to heat, oily skin, emotional instability, and defective judgment, are

increased by fatigue, excitement, and frustration. Palliative and symptomatic treatment of

the disease focuses on correcting the imbalance between depleted dopamine and

abundant acetylcholine in the striatum because dopamine normally appears to inhibit

excitatory cholinergic activity in this brain area. Levodopa, a dopamine precursor that

crosses the blood-brain barrier, may be used, but many patients experience side effects,

such as nausea, vomiting, insomnia, orthostatic hypotension, and mental confusion.

Carbidopa-levodopa, which contains an inhibitor of the enzyme dopa decarboxylase,

limits peripheral metabolism of levodopa and thus causes fewer side effects.

Anticholinergic drugs, such as benztropine mesylate, biperiden, procyclidine, and

trihexyphenidyl, may be used as therapeutic agents but often cause ataxia, blurred vision,

constipation, dryness of the mouth, mental disturbances, slurred speech, and urinary

urgency or retention. Amantadine hydrochloride, an antiviral drug with antiparkinsonian

activity, promotes the accumulation of dopamine in extracellular or synaptic sites, but the

therapeutic effectiveness may not last more than 3 months in some patients; side effects,

such as mental confusion, visual disturbances, and seizures, occur infrequently.

drug for parkinsons (primary one)

know trigeminal neuralga vs. bells palsy

guillan barre… most common type…

an idiopathic, peripheral polyneuritis that may occur 1 to 3 weeks after a mild episode of fever

associated with a viral infection or with immunization but that can also occur with no preceding

illness. Symmetric pain and weakness affect the extremities, and paralysis may develop. The

neuritis may spread to the trunk and face. Symptoms vary in intensity from mild to severe

enough to require critical nursing care, including ventilator assistance. Treatment consists of

supportive care and high IV doses of immunoglobulins. Recovery depends on the extent of

neuritis and may take weeks to many months. observations

Manifestations may range from mild to severe and generally develop 1 to 3 weeks after an upper

respiratory or gastrointestinal infection. The first sign is symmetric muscle weakness in the distal

extremities accompanied by paresthesia. This weakness spreads upward to the arms and trunk

and then to the face. This ascension usually peaks about 2 weeks after onset. Deep tendon

reflexes are commonly absent. Difficulty chewing, swallowing, and speaking may occur, and

respiratory paralysis may develop. Signs of autonomic nervous system dysfunction, such as

facial flushing, profuse diaphoresis, bowel and bladder atony, postural hypotension,

hypertension, tachycardia, and heart block, may develop. Deep, aching muscle pain is also

common. The diagnosis is based on history and clinical presentation. Lumbar puncture results

typically reveal an increase in cerebrospinal fluid protein without an increase in lymphocyte

count. Electromyography is markedly abnormal with reduced nerve conduction velocity. About

5% of those affected die of respiratory failure. Another 10% have permanent residual neurologic

deficits. About 90% of all survivors make a full recovery, but the recovery time may be as long

as 3 years.

interventions

Treatment is supportive, with the use of IV immunoglobulins or plasmapheresis to counteract

neurologic defect and speed recovery of neurologic deficit. Subcutaneous heparin is given to

prevent thromboembolism. Tracheostomy and mechanical ventilation are necessary to treat

respiratory paralysis, and breathing function tests should be performed and followed closely.

Continuous cardiac monitoring is done to detect possible sinus tachycardia and/or

bradyarrhythmias.

nursing considerations

Care for patients with Guillain-Barré disease is complex and multifaceted. In acute disease,

nursing focus is on careful assessment of ascending paralysis and monitoring of respiratory

function to ensure airway patency and adequate gas exchange. Continuing assessments are

needed of corneal, gag, and swallow reflexes. Blood pressure is monitored for fluctuations;

cardiac rate and rhythm are monitored for tachycardia, bradycardia, heart block, and asystole.

Pain assessment and management are required for paresthesias, hyperesthesias, muscle cramps,

and deep muscle aches. Complications related to autonomic dysfunction, paralysis, and

immobility (e.g., pressure sores, thromboemboli, aspiration, urinary retention, fecal impaction,

and nerve palsies) must be prevented. This includes a rigorous turning and positioning schedule,

regular passive range-of-motion exercises, careful pulmonary toilet and feeding routines,

application of thromboembolic stockings, and institution of bowel and bladder programs.

Communication systems may be needed if the individual is on a ventilator or has facial paralysis.

Emotional and social support are needed to reduce fear and anxiety. Rehabilitation may be

indicated for recovery of functional abilities and long-term adaptation to permanent neurologic

deficit.

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Restless leg syndrome (patient teaching):

any condition that interferes with normal sleep patterns, such as sleep apnea, phase shift, use

of alcohol and certain drugs, excessive sleepiness, sleep walking, nightmares, sleep paralysis,

restless leg syndrome, and narcolepsy. Treatment may include medications, relaxation,

avoidance of stimulants, and referral to sleep disorder clinics.

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Know what status epilepticus is

a medical emergency characterized by continuous seizures lasting more than 30 minutes

without interruption. Status epilepticus can be precipitated by the sudden withdrawal of

anticonvulsant drugs, inadequate body levels of glucose, a brain tumor, a head injury, a high

fever, or poisoning. Therapy includes IV administration of anticonvulsant drugs, nutrients,

and electrolytes. An adequate airway is usually maintained with a nasopharyngeal or

endotracheal tube.

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