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Ch. 70 Management of patients with degenerative neurologic disorders

Terms in this set (121)

Parkinsons disease:
• Common slowly progressing neurologic movement disorder that eventually leads to disability
o Affects men more than women
o Usually occurs after the age of 50
• The degenerative or idiopathic form of Parkinson's disease is the most common; there is also a secondary form with a known or suspected cause
• Cause of most cases is unknown→ there is definitely a genetic component
Parkinson's disease cont.:
• Research suggests several other causative factors → atherosclerosis, excessive accumulation of oxygen free radicals, viral infections (Encephalitis), head trauma, chronic use of antipsychotic meds, and some environmental/chemical exposures
o Reglin has been known to cause the development of Parkinson like symptoms
Parkinsons pathophysiology:
o Problems→decreased levels of dopamine
• Dopamine naturally has inhibitory effects on the body
• ACH (acetylcholine) naturally has an excitability effect on the body
• Imbalance with ACH (Myasthenia gravis) and dopamine (Parkinson's) is when tremors occur
Symptoms of parkinson don't appear until:
60% of the pigmented neurons are lost and dopamine has decreased by 80%.
o Treatment will involve some form of dopamine supplement (aka drugs with "dopa" in them)
Clinical manifestations of parkinsons:
TRAP—tremor, rigidity, akinesia/Bradykinesia (slow movement), postural instability
Tremor
1st clinical manifestation
• Slow, unilateral resting tremor present in the majority of patients at the time of diagnosis
• Tremor may manifest as pill rolling—slow turning motion (pronation, supination) of forearm and hand and a motion of the thumb against the fingers as if rolling a pill between fingers
• Characteristically disappears w/ purposeful movement & sleep but is evident when extremities are motionless/@rest
• Get worst when anxious, concentrating or stressed out
Rigidity
• Resistance to passive limb movement→ may cause the limb to move in jerky increments, referred to as lead pipe or cog wheel movements (can't make smooth movements)
• Involuntary stiffness of the passive extremity increases when another extremity is engaged in voluntary active movement
• Stiffness of arms, legs, face, and posture are common—Early in disease pt may complain of shoulder pain d/t rigidity
(Akinesia—lose voluntary movement) Bradykinesia
• Overall slowing of active movement—may take longer to complete activities and have difficulty initiating movement such as rising from a sitting position or turning in bed.
• Can be aggravating to family
• Tends to shuffle and exhibits decreased arm swing when walking
• As dexterity declines, micrographia (small handwriting) develops
• Face becomes increasingly masklike and expressionless, and the frequency of blinking decreases
Hypokinesia
abnormally diminished movement; common and may appear after the tremor
Freezing phenomenon
transient inability to perform active movement
• Can't move muscles back and forth or anything
• Is thought to be an extreme form of bradykinesia
Dysphonia
soft, slow, and slurred speech; low pitched and less audible
• Voice impairment/altered voice production d/t weakness & incoordination of muscle responsible for speech
• Often develop dysphagia→ start to drool→ At risk for aspiration and choking
Postural instability
(postural and gait problems d/t los of postural reflexes)
• Stands with head bent forward and walks with propulsive gait—very stiff
• Posture d/t forward flexion of neck, hips, knees, and elbows
• Shuffling, narrow gait—walks faster and faster, trying to move feet forward under the body's center of gravity
• Difficulty pivoting causes loss of balance→ High risk for falls
Autonomic Symptoms:
• Excessive and uncontrolled sweating
• Paroxysmal Flushing
• Orthostatic hypotension
• Gastric and urinary retention
• Constipation
• Sexual dysfunction
Psychiatric Changes:
• Depression and anxiety
• Dementia (progressive mental deterioration)
• Delirium
• Auditory or visual hallucinations
• Personality changes, psychosis, dementia, and acute confusion are common in older adult patients
Mental changes:
• Cognitive, perceptual, and memory deficits→ INTELLECT IS NOT USUALLY AFFECTED
Parkinsons complications:
o Respiratory—pneumonia
o Infections—respiratory and UTI
o Skin breakdown
o Injury from falls
o Medication complications→ lots of side effects
o As patients get older—cognitive decline is not normal!
• Don't use it, you lose it
Parkinsons diagnostic findings:
o Diagnosis is made clinically from patient history & presence of 2 out of the 4 TRAP symptoms
o Diagnosis confirmed by patient's response to medication→ not making enough dopamine so if we give them dopamine replacement and their symptoms improve then they are diagnosed with Parkinson's
Medical management: Levodopa
→ most effective agent
• Med is most beneficial in the first 1-2yrs of treatment then wanes and adverse effects become more severe over time→ confusion, hallucinations, depression, and sleep alterations associated with prolonged use
Medical management: Levodopa --> problems
effects decrease over time; dose must be constantly, gradually increased and can sometimes become toxic
o If toxic symptoms develop, may put them on "drug holiday"→ Put them in hospitals and take them off all levodopa—then start back off on lower dose
o 1920 STOPPED RECORDING
Levodopa cont.:
• Avoid vitamin B6→ lowers the amount of dopamine available to the patient; increase conversion of levodopa in the liver
Complications of levodopa:
o Dyskinesia (impaired ability to execute voluntary movements; seen w/in 5-10yrs)→ facial grimacing, rhythmic hand jerking movements, head bobbing, chewing/smacking movements, and involuntary trunk/extremities movements.
• Complicates the already present complications
o On-off syndrome→ medicine randomly stops working—will have sudden periods of near immobility, followed by sudden return of effectiveness of the medication
o NMS (neuroleptic malignant syndrome)→ potential complication from long-term use
• S/s—severe rigidity, stupor, and hyperthermia
• Extremely high temp would necessitate medication to be stopped
Medical management: Sentimet
combination of levodopa and carbidopa
• Carbidopa increases absorption of levodopa→ dopa increases dopamine uptake
Medical management: anticholinergics
→ trihexyphenidyl hydrochloride (Apo-Trihex), benztropine mesylate (Cogentin)
• Used for patients that can't tolerate Levodopa
Medical management: Antiviral agents
amantadine hydrochloride (Symmetrel)
• Effectiveness = 3 months (don't see often)
Medical management: Dopamine agonists
bromocriptine mesylate (Parlodel), pergolide (Permex)
• Stimulate dopamine receptors in brain and help prevent dopamine level fluctuations
• Nonergot Derivatives→ ropinirole hydrochloride (Requip), pramipexole (Mirapex)→ didn't say in class
Medical management: monoamine oxidase B inhibitors
→ selegiline (Eldepryl), rasagiline (Azilect)
• Used in early stages
• Inhibits enzyme that breaks down levodopa
Medical management: Catechol O-methyltransferase inhibitors
entacapone (Comtan) and tolcapone (Tasmar)
• Inhibits enzyme that breaks down levodopa
• Liver failure—significant side effect
Medical management: Antidepressants
bupropion hydrochloride (Wellbutrin)
• Tricyclic Antidepressants→ amitriptyline hydrochloride (Elavil)
o Anticholinergic and antidepressant
• SSRIs→ fluoxetine hydrochloride (Prozac)
o SE: clinical worsening and suicide risk→ don't want to give someone already suicidal
Medical management: Antihistamines
diphenhydramine hydrochloride (Benadryl), orphenadrine citrate (Banflex), phenylephrine hydrochloride (Neo-Synephrine)
• Helps reduce tremors
• Start on low dose then increase over time
Surgical management of Parkinson's:
• Surgery considered in patients with disabling tremor, rigidity, or severe levodopa-induced dyskinesia
• Surgery provides symptom relief in selected patients; it has not been shown to alter the course of the disease or to produce permanent improvement.
Surgical management: Stereotactic Procedures:
• Deep Brain Stimulation (DBS)—surgical implantation of an electrode into the brain in either the globus pallidus or subthalamic nucleus.
o Stimulation of these areas may increase dopamine release or block anticholinergic release, thereby improving tremor and rigidity.
Surgical management: Neural Transplantation
ongoing research
• Transplanting porcine neuronal cells, human fetal cells, and stem cells to replace degenerated striatal cells.
• Legal, ethical, & political concerns about using fetal brain cells & stem cells limits exploration of procedure
Nursing Diagnosis for parkinsons:
o Impaired physical mobility r/t muscle rigidity and postural impairment
o Self-care deficits (feeding, dressing, hygiene, and toileting) r/t tremor and muscle rigidity
o Constipation r/t medication and reduced activity
o Imbalanced nutrition: less than body requirements r/t tremor, slowness in eating, difficulty in chewing and swallowing
o Impaired verbal communication r/t decreased speech volume, slowness of speech, inability to move facial muscles
o Ineffective coping r/t depression and dysfunction d/t disease progression
Nursing interventions:
Maintain safety
Improving immobility
Enhancing swallowing
Improving communication
improving bowel elimination
improving nutrition
Enhancing self care activities
Nursing interventions: Preventing falls
• Monitoring for orthostatic hypotension
• Using gait belt when walking them
• Encourage to use wide spaced gait and stand up straight when walking (tell them to look at nurse when trying to stand up)
• Remind to slow down when walking
• Clear path for walking
• May need chest restraints when sitting in chair—not serving as a restraint, just used to prevent falling out
Nursing interventions: Preventing aspiration
swallowing difficulties; lots of secretions/drooling
• Keep suction by bedside; use as needed
• HOB elevated while eating
• Thickened liquids
• Massage face and neck muscles while eating helps (book says massage before eating)
Nursing interventions: Improving immobility
• Physical therapy beneficial
• Progressive program of daily exercise will increase muscle strength, improve coordination and dexterity, reduce muscular rigidity, and prevent contracture that occur when muscles are not used
• Duhon said routine "minimal exercise program"
Nursing interventions: Improving immobility cont.
• Walking, riding a station bicycle, swimming (Duhon said she wouldn't want her patient swimming d/t drowning risk), and gardening are all exercises that help maintain joint mobility
• Improve rigidity→ Stretching and ROM exercises promote joint flexibility; high back massages
Nursing interventions: Enhancing swallowing
• Swallowing difficulties and choking are common in Parkinson's disease
• Can lead to problems with poor head control, tongue tremor, hesitancy in initiating swallowing, difficulty in shaping food into a bolus, and disturbances in pharyngeal motility
• Sit upright position during mealtime
• Semisolid diet with thick liquids is easier to swallow than solids, thin liquids should be avoided
Nursing interventions: Enhancing swallowing cont.
• Patient taught to place the food on the tongue, close the lips and teeth, life the tongue and then back and swallow
• Encourage to chew first on one side of the mouth and then on the other
• Reminded to hold the head upright and make conscious effort to swallow
• Massing the facial neck muscles before meals may be beneficial
Nursing interventions: improving communication
slow slurred speech
• Reduce noise when they're trying to communicate
• Give them time to speak, don't interrupt them→ they can get frustrated
• Educate them to face the listener, exaggerate the pronunciation of words, speak in short sentences and take a few deep breaths before speaking
Nursing interventions: Improving bowel elimination
• Establish regular bowel routine—encourage the patient to follow a regular time pattern, increase fluid intake, walking, and eat foods with a moderate fiber content
• Laxative and enemas should be avoided unless all other options don't work and are absolutely necessary (last resort)
• A raised toilet seat is useful, because the patient has difficult in moving from a standing to a sitting position
Nursing interventions: Improving nutrition
decreased appetite
• Maximize nutrition—between meal supplements; small frequent high calorie meals, adequate time for eating and drinking (don't let dietary take tray before patient has time to finish), may need help feeding
• Monitoring weight on a weekly basis indicates whether caloric intake is adequate
• Supplemental feedings increase caloric intake
Nursing interventions: Improving nutrition
• As the disease progresses, a nasogastric tube or percutaneous endoscopic gastroscopy may be necessary to maintain adequate nutrition
• A dietitian can be consulted regarding nutritional needs
Nursing intervention: Enhancing self-care activities
want as independent as possible for as long as possible
• Encouraging, teaching, and supporting the patient during ADLs promote self care
• May need assistive devices when dressing
• Active ROM exercises to help with rigidity and keep as independent as possible
• A lot of education with go to care givers as well
• Environmental modifications
Nursing intervention: Encouraging the use of assistive devices
• Electric warming tray keeps food hot and allows the patient to rest during the prolonged time that it may take to eat
• Special utensils
Nursing interventions: Supporting coping abilities
• A combination of physiotherapy, psychotherapy, medication therapy, and support group participation may help reduce the depression that often occurs
Nursing intervention: promoting home and community based care
• Education is important in the management of Parkinson's disease
• Need for information is ongoing as adaptations become necessary
• Should include a clear explanation of the disease and the goal of assisting the patient to remain functionally independent as long as possible
Huntingtons disease
• Chronic, progressive, heredity disease of the nervous system that results in progressive involuntary choreiform (chorea) movement and dementia
• Exact cause is unknown
• Genetic marker has been identified—can identify people who will develop disease
Huntington disease cont.:
o Chorea: constant, rapid, jerky, involuntary, purposeless movements
• Affects walking, sleeping, EVERYTHING→ safety is priority
o Intellectual decline & dementia as progressive loss of brain cells in cortex
Huntingtons clinical manifestations:
o Age 35-45 onset; disease progresses slowly
o Most prominent clinical features: Chorea, impaired voluntary movement, intellectual decline, and often personality changes
o As the disease progresses, a constant writing, twisting, uncontrollable movement may involve the entire body
Huntingtons clinical manifestations: Cont.
• Motions are devoid of purpose or rhythm, although patients may turn them into a purposeful movement
• All of the body musculature is involved—Facial movements produce tics and grimaces
• Choreiform movements persist during sleep but are diminished
Huntingtons clinical manifestations: Cont.
• Gait becomes disorganized and ambulation eventually is impossible→ a wheelchair usually becomes necessary
• Eventually patient is confined to bed when the chorea interferes with walking, sitting, and all other activities
Huntingtons clinical manifestations: Cont.
o Speech becomes slurred, hesitant, explosive, and eventually unintelligent
o Chewing & swallowing difficult→ constant danger of choking & aspiration
o Bowel and bladder control completely lost
o Despite ravenous appetite, pts usually become emaciated and exhausted
o Die within 10-20 years d/t HF, pneumonia, or infection (pressure ulcers), or as a result of a fall or choking
Huntingtons clinical manifestations: Cont.
o Cognitive function usually affected, and in later stages dementia present
• Initially patient is aware that disease is responsible for the dysfunctions occurring
• The mental and emotional changes may be more devastating to the patient and family than the abnormal movements
• Personality changes—nervous, irritable, or impatient behaviors
Huntingtons clinical manifestations: Cont.
• Early stages—uncontrollable fits of anger, profound and often suicidal depression, apathy, anxiety, psychosis, or euphoria
• Judgment and memory impaired→ dementia eventually ensues
• Hallucination, delusions, and paranoid thinking may precede the appearance of disjointed movements
Assessment and diagnostic findings for huntingtons disease:
o Made based on the clinical presentation of the characteristics symptoms, a positive family history, the known presence of a genetic marker (via blood test), and exclusion of other causes.
Management of huntingtons:
o No tx halts or reverses underlying process, meds may reduce chorea
o Threat of suicide is present particularly early in the course of the disease
o Psychotherapy aimed at relieving anxiety and reducing stress may help
Medications for treating Chorea: Tetrabenazine (Xenazine)
only approved drug for the treatment of the chorea
Medications for treating Chorea: Thiothixene hydrochloride (Navane), haloperidol decanoate (Haldol)→
blocks dopamine receptors
• Have been used in the past for treating chorea
Medications for treating Chorea: Benzodiazepines and neuroleptic drugs
have been reported to control chorea
Motor signs must be assessed and evaluated on an ongoing basis so optimal therapeutic drug levels can be reached:
Akathisia (motor restlessness) in overmedicated patient is dangerous because it may be mistaken for the restless fidgeting of the illness and consequently may be overlooked.
Motor signs must be assessed and evaluated on an ongoing basis so optimal therapeutic drug levels can be reached: Cont.
• In certain types of the disease, hypokinetic motor impairment resembles Parkinson's disease
o In patients who present with rigidity, some temporary benefit may be obtained from antiparkinson's medications→ levodopa
Medications for treating Psychiatric symptoms of huntingtons:
• SSRIs and Tricyclic Antidepressants→ psychiatric symptoms
• Antipsychotic medications→ psychotic symptoms
• Patients who have emotional disturbances, particularly depression, maybe helped by antidepressant medication
Management of huntingtons: Promote safety
high risk for suicide—put on suicide watch; wrap IV arm with gauze and use arm board, add extra tubing
Management of huntingtons: Continuing care
→ Home care, long term care centers, hospice→ eventually palliative care
• Huntington disease exacts enormous emotional, physical, social, and financial tolls on every member of the pts family
ALZHEIMERS DISEASE
• Two different types:
o Familial or early onset—rare; frequently associated with genetic mutations and occurs in middle-aged adults
o Sporadic or late onset—most common; seen later in life
Alzheimers disease pathophysiology:
Neuronal (nerve) damage occurs primary in cerebral cortex and results in decreased brain size
o Progressive, irreversible, degenerative neurological disease characterized by gradual loss of cognitive function and disturbances in behavior and affect
o Can occur in as young as 40 but usually not before 65
Alzheimers disease pathophysiology: cont.
o Prevalence increases with age→ AD IS NOT A NORMAL PART OF AGING
o Complex brain d/o caused by various factors: Genetics, neurotransmitter changes, vascular abnormalities, stress hormones, circadian changes, head trauma, and presence of seizure disorders
Diagnosis of Alzheimers:
autopsy brain biopsy (shows decreased brain size)
Clinical manifestations of Alzheimers:
o 1st signs→ Forgetfulness and memory loss (usually mistaken for normal signs of aging)
o Lose ability to recognize familiar objects, places, or faces
o Conversation becomes difficult due to cognitive decline→ hard to find words they are trying to say and they get frustrated
o Can't recognize consequences to their behaviors→ results in impulsive behaviors
Clinical manifestations of Alzheimers:
o Difficulty with everyday activities—can't take care of themselves
o Personality changes—depression (very common), suspicious (think people stealing from them), paranoid, hostile, combative
o Death results from complications of pneumonia, dehydration, respiratory failure
Medical management:
o No cure; slow disease progression→ Control symptoms
Medical management: • Cholinesterase inhibitors (CEI)→ donepezil hydrochloride (Aricept), rivastigmine tartrate (Exelon), galantamine hydrobromide (Razadyne formerly known as Reminyl)
• Helps decrease memory loss—enhance acetylcholine uptake in brain
• Used for mild-mod cognitive symptoms
• May improve w/in 6-12mo of therapy—recommended tx continue at least through moderate stages
Medical management: Combo of CEI with memantine (Namenda)
May be useful with mild-mod cognitive symptoms
Medical management: Behavioral symptoms
• Agitation and psychosis→ Behavioral and psychosocial therapies
• Depression and behavioral problems→ treated pharmacologically if other interventions fail
• Duhon said tx with antidepressants
Medical management of alzheimers cont.:
o Because symptoms change over time, all AD pts should be reevaluated routinely, and the nurse document and report both positive and negative responses to medications
Nursing management of Alzheimers: Supporting cognitive function
• Keep as independent as possible for as long as possible
• Need to be in calm predictable environment (somewhere they're familiar with)
• Limit environmental stimuli
• Regular routine established
Nursing management of Alzheimers: Supporting cognitive function cont.
• If in nursing home, may have color coded rooms to help locate rooms
• Display clocks and calendars to help orient them
• Use simple explanations and use memory aids and cues to help minimize confusion and disorientation
• Physical activity and communication shown to help cognitive decline
Nursing management of Alzheimers: Providing physical safety
• Obvious hazards removed and hand rails installed in the home to reduce risk of falls
• Adequate lighting, especially in halls, stairs, and bathrooms
• Should wear a med bracelet
• All activities outside the home should be supervised
Nursing management of Alzheimers: Providing physical safety cont.
• Sundown syndrome—increased confusion at night
• Wander around the house, may get out and wander the streets
• Lock doors from outside—creates safety hazard
• Have sitter for at night
• Night lights helpful
Nursing management of Alzheimers: Providing physical safety cont.
• Driving prohibited and smoking allowed only with supervision
• Gentile persuasion—don't like to be given orders; can be a handful
• Shouldn't live alone
• If at hospital and wandering—gentle persuasion, distraction, and place close to nurses station
• Avoid restraints—increase agitation
Nursing management of Alzheimers: Promoting independence in self care
• Simplify daily activities—organize into short, achievable steps so patient feels accomplished
• Occupational therapy can suggest ways to simplify tasks or recommend adaptive equipment
• Direct patient supervision sometimes necessary
• Maintaining personal dignity and autonomy is important→ encourage to make choices when appropriate and participate in self-care as much as possible
Nursing management of Alzheimers: Reducing anxiety and agitation
• Provide constant emotional support
• Environment kept familiar and noise free
• Structuring activity
• Become familiar with patient's predicted responses to certain stressors helps caregivers avoid bad situations
• Dementia education for caregivers—can be effectively taught by geriatric advanced NPs
Nursing management of Alzheimers: Reducing anxiety and agitation cont.
• Excitement and confusion can be upsetting and may precipitate combative, agitated state known as catastrophic reaction (overreaction to excessive stimulation)→ may scream, cry, become abusive physically or verbally
• If this occurs, remain calm and unhurried
• Forcing the patient to proceed with the activity only increases agitation
• Better to postpone the activity until later, even to another day
• Frequently they forget what triggered the reaction
• Measures such as moving to familiar environment, music, stroking, rocking, or distraction may quiet patient
Nursing management of Alzheimers: Improving communication
• Nurse should remain unhurried and reduce noises and distractions
• Use clear, easy to understand sentences
• Tactile stimuli, such as hugs or hand pats, are usually interpreted as signs of affection, concern, and security
Nursing management of Alzheimers: Improving communication cont.
• In early stages—lists and simple written instructions that serve as reminders may be helpful
• In later stages—patient may point to objects or use nonverbal language to communicate
Nursing management of Alzheimers: Promoting adequate nutrition
may not want to eat
• Provide foods they like, simple meals, may need help feeding themselves
• If adaptive equipment or hands are used to eat, use apron or smock to cover clothes, NOT BIBS
• Worry about aspiration and choking—cut food into small pieces, liquids may need to be converted to gelatin
Nursing management of Alzheimers: Promoting adequate nutrition cont.
• Make sure they are drinking enough fluids
• To avoid "playing" with food offer one dish at a time
• Hot food and beverages are served warm and temperature checked prior to prevent burns
Nursing management of Alzheimers: Promoting balanced activity and rest
• Organize activity after sleep
• Long naps during the day are discouraged
• Encourage physical activity during day
Nursing management of Alzheimers: Supporting home and community based care
• A lot of education to family and care givers about keeping safe at home
AMYOTROPHIC LATERAL SCLEROSIS (ALS)—Steven Hawking
• Progressive degeneration of both upper and lower motor neurons
o Unknown cause; there is a loss of motor neurons (nerve cells controlling muscles) in the anterior horns of the spinal cord and the motor nuclei of the lower brain stem
o As motor neuron cells die, the muscle fibers that they supply undergo atrophic changes
o Leading theory→ overexcitation of nerve cells by neurotransmitter glutamate results in cell injury and neuronal degeneration
o Possible causes include autoimmune disease, free radical damage, and oxidative stress
Diagnostic tests for ALS:
No definitive test, → based on s/s
o The prognosis generally is based on the area of CNS involvement and the speed with which the disease progresses
Clinical manifestations of ALS:
o Depends on which motor neurons are affected 1st → gradually all motor function will be lost regardless
o Chief symptoms→ fatigue, progressive muscle weakness, cramps, fasciculation (twitching), and incoordination
Clinical manifestations of ALS:
• Difficulty in talking, swallowing, and (ultimately) breathing occurs
• Eventually respiratory function is compromised→ Will need to be put on ventilator (susceptible to fungal infections)
• Death usually occurs as a result of infection, respiratory failure or aspiration
• Cognitive function does not decline with this
Medical Management of ALS:
o No cure (Ice bucket challenge was to raise money for research)
o Focus is on interventions to maintain or improve function, well-being, and quality of life
o Average survival time is 3-5 years
Medical Management of ALS--> Medications: Riluzole (Rilutek)
glutamate antagonist; unclear how it works
• Only medicine approved for treatment
• Prolong survival for 3-6mo—limited effects for improving muscle strength
Medical Management of ALS--> Medications: Baclofen (Lioresal), dantrolene sodium (Dantrium), diazepam (Valium)
muscle relaxers
• Helps with spasticity, which causes pain and interferes with self-care
Medical Management of ALS--> Medications: Modafinil (Provigil)
• Helps with fatigue
Medical Management of ALS--> Medications:
• Additional medications may be added to manage the pain, depression, drooling, and constipation
Nursing interventions for ALS:
o Comfort measures
o Maintain nutrition
o Prevent dehydration
o Prevent complications from paralysis
Patient Undergoing a Cervical Discectomy: Preoperative assessment
o Evaluate labs
o Get baseline functioning—strength bilaterally, ROM, etc.
• So you can determine improvement or decline post op
o Assess for medical conditions that may increase risk for complications—cardiac problems, respiratory problems (COPD, lung disease), liver and kidney problems, obesity, diabetes (high risk for infection—manage glucose throughout)
Patient Undergoing a Cervical Discectomy: Preoperative assessment cont.
o Ask about past injuries to the neck
o Assessment includes determining the onset, location, and radiation of pain and assessing for paresthesia, limited movement and diminished function of the neck, shoulders, and upper extremities
o Important to determine if symptoms are bilateral; in large herniation, bilateral symptoms may be caused by cord compression
o Area around the cervical spine is palpated to assess muscle tone and tenderness
o Range of motion in the neck and shoulders is evaluated
Patient Undergoing a Cervical Discectomy: Preoperative assessment cont.
o Asked about any health issues
o Also important to assess mood and stress levels
o Determine the patients need for information about the surgical procedure and reinforces what the physician has explained
o Strategies for pain management are discussed with the patient
Nursing diagnosis for Cervical disectomy:
o Acute pain related to the surgical procedure
o Impaired physical mobility related to the postoperative surgical regimen
o Deficient knowledge about the postoperative course and home care management
Complications of Cervical diseconomy:
o Hematoma at the surgical sites (donor and surgical), resulting in cord compression and neurologic deficit
• Hematoma = big hard knot
o Recurrent or persistent pain after surgery
Planning and goals after cervical disectomy:
o Relief of pain, improved mobility, increased knowledge and self care ability, and prevention of complication
Nursing interventions: Relieving pain
Kept flat for procedure for long time—causes discomfort and pain
• Monitor incision site→ Incisional pain expected; monitor for hematoma formation
• Radicular pain improves over time as nerve recovers
• If patient had bone fusion with bone removed from iliac crest, considerable pain pay be experienced at donor site
• Monitor the donor site for hematoma formation (big hard knot=blood aka bruising under skin)
Nursing interventions: Relieving pain cont.
• Administer prescribed postoperative analgesic agent
• Position for comfort
• Reassure the patient that the pain can be relieved
• If patient experiences a sudden increase in pain, extrusion of the graft may have occurred, requiring reoperation
Nursing interventions: Relieving pain cont.
• Sudden increase in pain should be reported to surgeon
• Throat lozenges, voice rest and humidification relieve sore throat, hoarseness, and dysphagia d/t temporary edema
• A pureed diet may be given if the patient has dysphagia until they can swallow properly
• At risk for aspiration d/t sore throat
Nursing interventions: Improving mobility
• Cervical collar is usually worn, which contributes to limit neck motion and altered mobility
• Instructed to turn the body instead of the neck when looking from side to side
• Neck should be kept in neutral position
• Keep patient in proper alignment→ LOG ROLL TO MOVE
Nursing interventions: Improving mobility cont.
• Patient is assisted during position changes, to make sure that head, shoulder, and thorax are kept aligned
• When assisting the patient to a sitting position, the nurse supports the patients neck and shoulders
• To increase stability, the patient should wear shoes when ambulating
Nursing interventions: Monitoring and managing potential complications
• Evaluate for bleeding and hematoma formation→ assess for excessive pressure in neck or severe pain in incision area
• Dressing inspected for Serosanguineous drainage→ suggests a dural leak
• Leak = high risk for meningitis→ monitor for severe HA, photophobia, s/s of meningitis (not neck rigidity)
• Neurologic check are made for swallowing deficits and upper and lower extremity weakness, because cord compression may produce rapid or delayed onset of paralysis
Nursing interventions: Monitoring and managing potential complications cont.
• Monitored frequently to detect any signs of respiratory difficulty d/t laryngeal nerve damage from retractors during surgery→ resulting in hoarseness and the inability to cough effectively and clear pulmonary section
• The blood pressure and pulse are monitored to evaluate cardiovascular status
Nursing interventions: Monitoring and managing potential complications cont.
• Severe localized pain not relieved by analgesic agents should be reported to the surgeon
• A change in neuro status should be reported promptly, because it suggests hematoma formation that may necessitate surgery to prevent irreversible motor and sensory deficits
Patient teaching/self-care with cervical diseconomy:
• Report increased pain, fever, drainage, swelling
• Stay is likely to be short in hospital
• Cervical collar worn for about 6 weeks → wash with mild soap twice daily
Patient teaching/self-care with cervical diseconomy:
• Alternate tasks that involve minimal body movement with tasks that require greater body movement
• Recurrent or persistent pain may occur despite removal of the offending disk or disk fragments
Evaluation for ALS:
o Monitor for bleeding and hematoma
o Reports decreasing frequency and severity or pain
o Demonstrates improved mobility
o Is knowledgeable about postoperative course, medications, and home care management
o Has absence of complications
POSTPOLIO SYNDROME
• People who survived the polio epidemic of the 50's are now developing new symptoms of weakness, fatigue, and musculoskeletal pain
o 80% of the 1 million polio survivors are experiencing the phenomenon
• The exact cause is unknown—think virus was dormant in body for so long so now it's coming back
• No specific diagnostic test—based on history of polio and clinical symptoms (have to rule out other causes of symptoms 1st)
o Bone density test reveals loss of bone mass, osteoporosis→ high risk for fractures and falls
Nursing interventions for postpolio syndrome:
o Assist with management of fatigue, pain, and progressive loss of muscle strength
o Heat/cold application
o Pain medications
o Pulmonary promotion—breathing, turning, coughing
Nursing interventions for postpolio syndrome: cont.
o Adequate fluids
o PT, OT therapy—usually treated at home
o Come to hospital usually for respiratory problems r/t the syndrome
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