N444: Test 5

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N444: Test 5 by Mind Map: N444: Test 5

1. Musculoskeletal

1.1. Review Topics

1.1.1. A&P Functions Protecting vital organs Mobility, movement Blood return to the heart RBC production Reservoir Structure Bones Joints Muscles

1.1.2. Assessment Collect data r/t functional abilities ADLs IADLs Various activities Mobility problems Health history General info FH Nutrition Occupation Learning needs Socioeconomic factors Medications Pain & altered sensation Physical exam Posture Gait Bone integrity Joint function Muscle strength & size Skin Neurovascular

1.1.3. Diagnostics X-ray CT MRI Biopsy Labs Arthography Bone densitometry Bone scan Arthroscopy Arthrocentesis Electromyography

1.2. Rheumatoid Arthritis

1.2.1. Overview Type of "rheumatic disease" "Arthritis" 100+ different diagnoses Mainly affect joints Classifications Chronic, diffuse CT disease Group of disorders Diffuse inflammation, degeneration Unknown cause, but may be immunologic Characterized by exacerbations & remissions Autoimmune, idiopathic Systemic, but mainly in synovial tissue 1% of world's population Female > males

1.2.2. Manifestations See patho for articular S/S Fever Weight loss Fatigue Anemia Lymphadenopathy Raynaud phenomenon Vasospastic disorder Discoloration of fingers, toes Caused by overactivation of SNS >> VC >> hypoxia Rheumatoid nodules Arteritis Neuropathy Scleritis Pericarditis Splenomegaly Sjogren syndrome Autoimmune disease Immune cells destroy certain exocrine glands Appears as generalized dryness (esp. eyes, mouth)

1.2.3. Pathophysiology Phagocytosis in joint >> Enzymes produced >> Collagen breakdown Edema Proliferation of synovial membrane Pannus formation Causes problems Loss of joint motion Loss of tendon & ligament elasticity Loss of contractile power

1.2.4. Assessment Bilateral/symmetric manifestations Stiff Tender Swollen Temperature changes @ joint Weight loss Sensory changes Lymphadenopathy Fatigue

1.2.5. Diagnostics Rheumatoid factor Increased ESR Decreased RBCs Decreased C4-compliment CRP + ANA + Arthrocentesis X-Ray

1.2.6. Management Medical Early Moderate, erosive Persistent, erosive Advanced, un-remitting Nursing NSAID education Nutrition therapy Nursing process Home care Depends on severity Assessment issues Referrals Goals Education

1.3. Osteoarthritis

1.3.1. Degenerative joint disease Most common, disabling Primary or secondary Directly r/t to increasing age 90% have DJ changes by 40 In weight-bearing joints W/o clinical symptoms

1.3.2. Pathophysiology Cartilage degradation Bone stiffening Inflammation of synovium Certain areas affected Articular cartilage Subchondral bone Synovium

1.3.3. Risk factors Disorders of the hip Increased age Obesity Previous joint damage Repetitive use Anatomic deformity Genetics

1.3.4. Manifestations Pain Stiffness AM or after wakening Lasts <30 min Decreases w/movement Functional impairment R/t pain with movement Limited ROM r/t structural changes

1.3.5. Affected areas Weight-bearing joints Proximal and distal finger joints

1.3.6. Diagnostics Blood tests = not useful X-ray results Visible narrowing of joint space Osteophytes Tender, enlarged joints on exam Inflammation* May be present Not destructive kind like RA

1.3.7. Management Cannot HALT degeneration May slow progression Weight reduction Prevent injuries Screen for congenital hip dx Ergonomics Treatment Education Heat packs Joint rest Orthotics Isometric exercise Alternative therapies Medications Surgery Nursing care Education Pain management (non-pharm first) PT, exercise, assistive devices Weight reduction 10 hours of sleep @ night + 1-2 hr nap Alternative therapies

1.4. Gout

1.4.1. Overview Genetic defect of purine metabolism Oversecretion Decreased kidney excretion BOTH Causes hyperuricemia Two types Primary Secondary Common drug: allopurinol Up to 3L of fluid per day No organ meats or wines IUOP to 2L per day

1.4.2. Risk factors Older age Higher BMI Gender Lifestyle factors Alcohol Diet Family history Medications

1.4.3. Pathophysiology Serum uric acid > 7 mg/dL Attacks r/t sudden changes in uric acid Formed during purine breakdown >> High uric acid >> urate crystals >> Precipitate w/i joint >> Inflammation >> gout attack + pain May progress to tophi, kidney stones Attacks gradually worsen Occur more frequently Involve more joints Last longer

1.4.4. Manifestations PM onset usually Big toe most affected Pain Redness Swelling Warmth

1.4.5. Diagnosis Polarized light microscopy of synovial fluid Visible uric acid crystals

1.4.6. Treatment Medical Acute attacks Management Nursing care Dietary restrictions Normal body weight Pain management Compliance b/w attacks

1.5. Osteoporosis

1.5.1. Pathophysiology Altered bone turnover Rate of resorbation > rate of formation Loss of total bone mass Porous, brittle, fragile bones

1.5.2. Common areas Spinal compression fractures Neck fractures Femur fractures Colles' fractures (wrists)

1.5.3. Early sign: loss of height

1.5.4. Risk factors Slight frame Non-obese Asian or Caucasian Women > men* Occurs later for men Lack of Ca/Vitamin D Bariatric surgery (duodenum bypass) Immobility Casts, sedentary, paralyzed, etc Must get patients weight-bearing ASAP!

1.5.5. Prevention Lifelong diet w/Ca & Vitamin D Calcium supplements + Vitamin C Weight-bearing exercise (esp. walking) Weight training to improve BMD

1.5.6. Pharmacology Bisphosphonates End in -dronate Fosamax, Actonel Boniva Selective estrogen modulators SERMs Evista Calcitonin Teriparatide (Forteo) Ca and Vitamin D

1.5.7. Diagnostics X-ray Poor indicator Has to be 25-40% demineralized DXA scan (Recommended) All women >65; men >70 Postmenopausal women Men >50 w/risk factors + associated fracture Determines OP, osteopenia, & therapeutic responses

1.5.8. Management Prevention, then early intervention Reduce bone loss, fractures

1.5.9. Nursing process Assessment Osteopenia, OP history Family history Fractures Calcium in diet Exercise Menopause Other factors Diagnoses Deficient knowledge Acute pain Risk for constipation Risk for injury Planning Knowledge Pain management Bowel elimination Fracture prevention Implementation Education about process, treatment Pain relief Bowel elimination Preventing injury

1.6. Osteomalacia

1.6.1. Metabolic bone disease Inadequate mineralization Lack of activated Vitamin D >> Poor mineralization, low Ca and P Become soft, weak Pain, tenderness, deformities Bowing of legs, pathologic fractures

1.6.2. Causes GI disorder Severe renal insufficiency Hyperparathryoidism Diet deficiency

1.6.3. Treatment R/t underlying cause Increase Vitamin D and Ca Handle gently >> high risk for fractures! Pain management

1.7. Paget's Disease

1.7.1. AKA ostetitis deformans Disorder of localized bone turnover Very rare (2-3% of age 50+) Men > women Increased risk with age Family predisposition

1.7.2. Pathophysiology Excess resorption by osteoclasts >> Increased osteoblastic activity >> Disorganized, weak, highly vascular bones Increased risk of fractures, arthritis, hearing loss

1.7.3. Manifestations Skeletal deformities Mild to moderate, aching pain Tenderness, warmth over bones Insidious onset May be asymptomatic

1.7.4. Pharmacology NSAIDs for pain Calcitonin Bisphosphonates Plicamycin (Mitracin) Cytotoxic antibiotic May be used for resistent, severe form

1.8. Surgeries & Nursing

1.8.1. Indications Joint disease Deformities Unstable fractures Necrotic, infected tissues Tumors

1.8.2. Goals Improve function Relieve pain, disability

1.8.3. Many types

1.8.4. Patient needs Mobility/ambulation Within a day of post-op Using assistive devices Weight-bearing as prescribed Drain use Bleeding Fluid accumulation Infection prevention Immediate (w/i 3 months) Delayed (4-24 months) Due to spread (+2 years) DVT prevention Education and rehab

1.8.5. Joint replacement Total Hip Replacement Indications Prosthesis Pre-op care Post-op care Total Knee Replacement OA or RA Metal or acrylic prosthesis Nursing care

1.8.6. Nursing process Assessment Pre-op Post-op Diagnoses Acute pain Risk for peripheral NV dysfunction Risk for ineffective therapeutic regimen management Impaired phys mobility Risk for situational low-self esteem Collaborative problems Planning Pain relief NV function Health promotion Mobility Self-esteem Avoid complications Intervention Muscle settings, exercises Nutrition, hydration Skin integrity Asepsis, infection prevention PT, rehab Realistic goals Self-care as appropriate RR status (TCDB, IS) Education Monitoring for shock

1.9. Degenerative Disk Disease

1.9.1. Background Most common cause of low back pain Degenerative with age or trauma Radiculopathy >> Pain Continued pressure >> more degeneration Altered sensation, motor ability Conservative treatment Rest Medications Surgery** Assessment H&P MRI (CT, myelography if needed) Neuro exam

1.9.2. Cervical disk hernia Stress from age, occupation Spondylosis Degeneration in disk Includes associated vertebral bodies Manifestations Variable - C5-6 or C6-7 Pain & stiffness Pain & parasthesia Treatment Bedrest 1-2 days Immobilization Pharmacological Hot, moist compress for 10-20 min Cervical discectomy

1.9.3. Lumbar disk hernia Manifestation Low back pain w/spasm Radiation of pain to leg (sciatica) Pain Diagnostics H&P MRI CT Myelography Nursing process Assessment Diagnoses Planning Interventions Medical management 1-2 days bed rest Non-pharmacologic Pharmacological Lumbar disk excision Complications Relapse Adhesions, scarring r/t inflammation Perisistent effects from neural injury Failed disk syndrome

1.10. Upper Extremity Conditions

1.10.1. Diagnoses Bursitis/tendinitis Loose bodies Impingement syndrome Carpal tunnel syndrome Tinel's sign Ganglion Dupuytren's contracture

1.10.2. Surgical care Outpatient procedure Need education NV checks q1 hr for first 24 Motor function as prescribed S/S to report Pain control Meds Elevation Intermittent ice, cold Infection prevention ADLs Assistance Promote independence

1.11. Lower Extremity Conditions

1.11.1. Diagnoses Plantar fascitis Corn Callus Ingrown toenail Hammer toe Hallux valgus Clawfoot (pes cavus) Morton's neuroma Flatfoot (pes planus)

1.11.2. Surgical care Assessment Outpatient Routine pre-op Patient education NV checks Ambulation, balance Home care needs Diagnoses Risk for ineffective peripheral tissue perfusion Acute pain Impaired phys mobility Risk for infection Planning Adequate perfusion Pain relief Improved mobility No complications Interventions NV assessment Pain management Improving mobility Infection prevention Patient education

2. Cancer

2.1. General

2.1.1. Unchecked cell growth Potentially dangerous Malignant > benign Common sites More dangerous than benign b/c metastasizes Metastases share name of original, primary tumor site

2.1.2. At high risk for infection Atypical presentation Subnormal temperature Changes in behavior

2.1.3. Top cancers in USA Lung Breast/prostate Colorectal

2.1.4. Gerontological considerations Immunity Drug absorption alterations Co-morbidities Decreased reserves Lung Cardiac Neuro Renal Decreased defenses Musculoskeletal strength Skin integrity Neurosensory Social, economic resources Presentation may seem normal (r/t to age) Vulnerable to complications Cancer Cancer treatment Functional status Consideration during treatment

2.1.5. Carcinogens Viruses HPV Hep B EBV Radiation Diagnostics Sunlight Tanning Chemicals Chemo! Tobacco Hormones (DES) Aromatic hydrocarbons

2.1.6. Theories & Categories Gompertzian growth Theory Clinical staging 0: Cancer in situ 1: Tumor limited/localized 2: Limited local spread 3: Extensive local & regional spread 4: Metastasis TNM classification Tumor size, invasiveness (T) Spread to lymph nodes (N) Metastasis (M) Differentiation Grade 1: Well-differentiated Grade 2 Grade 3 Grade 4: Poorly differentiated (high-grade) Undifferentiated (anaplastic)

2.1.7. C.A.U.T.I.O.N. Seven warning signs of cancer Change in bowel/bladder habits A sore that doesn't heal Unusual bleeding/discharge Thickening in breast or elsewhere Indigestion (dysphagia) Obvious change in wart or mole Nagging cough or hoarseness

2.2. Prevention

2.2.1. Primary Avoid known carcinogens Diet, lifestyle changes

2.2.2. Secondary Genetic testing Breast cancer risk Family adenomatosis polyposis r/t colon cancer Teaching about decreasing risk

2.3. Diagnosis

2.3.1. Extensive MRI, CT, PET Fluroscopy, endoscopy Ultrasound Nuclear imaging Radioimmunoconjugates (tagging) Tumor marker testing

2.3.2. Purposes ID presence, extent of tumor Spread or invasian Function of systems/organs Specimens

2.4. Treatment

2.4.1. Goals Cure: Disease free for 5+ years Increased potential if local only Depends on malignancy, stage at diagnosis Control Palliation

2.4.2. Modalities Surgery Oldest form Meets many goals Several purposes Nursing care Radiation High-energy ionizing radiation Methods of delivery Purposes Dosage Complications Nursing care Chemotherapy Routes Types CAM Effects Complications NADIR Neutropenia

2.5. Infection

2.5.1. Leading COD in cancer patients

2.5.2. Unusual presentation in BMD NO FEVER! Why? B/c a fever is a healthy immune response

2.5.3. Symptoms Fever Flushing, diaphoresis Shaking, chills White patches in mouth Erythema, swelling, heat/pain Sputum changes Urinary frequency, burning Flui-like symptoms Rash or skin changes

2.5.4. Nursing care Assessment ROS Invasive lines Interventions Growth hormones (Procrit, etc) >> WBCs Neutropenic diet Environmental changes

2.6. Bleeding

2.6.1. Thrombocytopenia 50k-100k @ mild risk 20k-50k @ moderate risk <20k @ severe risk for non-traumatic bleeding <10k: fatal CNS, GI, RR hemorrhage

2.6.2. Nursing care Monitor labs HgB <10 = poor QOL HgB <8 = expect transfusion orders Assess bleeding Avoid invasive procedures when possible Administer blood products

2.6.3. Anemia Very low RBCs Quality of HgB and/or volume PRC Variable levels Males: HgB <13.0; HCT <42 Females: HgB <12.0; HCT <36

2.7. Specific Cancers

2.7.1. Lung Poor prognosis (15% 5-year survival rate) Can be caused by irritants >> cells replaced by dysplastic cells Types SCLC NSCLC Manifestations Coughing, wheezing, stridor Thick, purulent sputum Hemoptysis Dyspnea Back or shoulder pain Weight loss Fatigue Risk factors Tobacco Environment Occupational hazards Complications Pneumonia/PE Cushing's Hypercalcemia Anemia DIC SIADH SVCS Suspicious presentation Diagnostics Labs PFT's Evaluate for mets Post-op care Prevent & detect complications Breath souds q2-4hrs Constant observation of RR distress No deep suctioning DVT prevention C&DB Pain relief Positioning Discharge teaching Pain control Oxygen equipment Postural drainage Energy conservation Exercises Monitoring

2.7.2. Breast Common presentation Hard, irregular, fixed, painless lump Usually unilateral & in UOQ Other symptoms Risk factors Age +40 High SES Early menarche Late menopause Medical management Chemo Radiation Surgery Mastectomy care Pre-op Post-op Complications

2.7.3. Gastrointestinal Sub-types Gastric Colon Risk factors Diet Smoking Family history Chronic GI inflammation Urban living Poor diet

2.7.4. Brain tumors Benign or malignant Manifestations Local or general neuro symptoms Symptoms of IICP HA Vomiting Vision disturbances Hormonal effects (pit. adenoma) Loss of hearing, tinnitus, vertigo (acoustic neuroma) Pathologic events IICP Seizures Hydrocephalus Altered pituitary fxn

2.7.5. Spinal cord tumors Intra- or extra-medullary Manifestations Pain Weakness Loss of motor fxn, reflexes, sensations Treatment based on type/location Surgical removal Decompression

2.7.6. Skin cancer Frequently r/t sun exposure Three key types Basal cell carcinoma Squamous cell carcinoma Malignant melanoma

2.8. Oncologic Emergencies

2.8.1. SVC syndrome Compression of SVC >> obstructed venous blood flow Tumor Enlarged lymph node Thrombus May obstruct head, neck, arms, thorax Manifestations Progressive dyspnea** Cough/hoarseness Chest pain Edema JVD Dysphagia IICP Diagnostics Manifestations X-Ray of chest CT scan of chest MRI of chest Nursing care Diagnoses ID @ risk patients Monitor, report S/S VS, mental status Position for oxygenation Fluid, electrolyte status No blood draws or BP to BUE Management Radiation/chemo Thrombolytics (heparin IV) Percutaneous stent (heart cath) Oxygen therapy Corticosteroids (solumedrol) Diuretics (lasix, mannitol)

2.8.2. Spinal cord compression Pathophysiology Compression of spinal cord or nerve roots Tumor, lymphoma, lack of blood flow, or intervertebral collapse Manifestations Inflammation, edema, venous stasis to nerves Upper back/neck pain Pain that worsens w/movement Sensory alterations Weakness Flaccid paralysis Bladder, bowel dysfunction Nursing care Neuro assessment Pain management Active & passive ROM Complications r/t immobility Bowel, bladder training Support patient/family Nursing diagnoses Medical management Radiation/chemo Surgery Vertebroplasty Diagnostics Abnormal reflexes MRI, CT X-Ray Bone scans Myelogram

2.8.3. Tumor lysis syndrome Rapid breakdown of tumor Release of cell contents Causes 4 key electrolyte imbalances Associated w/chemo, radiation, biotherapy Leukemias, lymphomas, SCLC Can be fatal! Nursing care Diagnoses ID at risk patient w/i 1st week of therapy Electrolyte levels S/S electrolyte imbalances IV fluids, PO meds as ordered Medical management Balance electrolytes w/IV Diuretics Allopurinol PO Kayexelate PO Renagel/Renveala PO Hemodialysis**

2.8.4. Hypercalcemia Pathophysiology Release from bones > kidney excretion Bone reabsorption of excess Bone breakdown r/t several factors Manifestations Fatigue/weakness Hyperreflexia AMS Decreased LOC N/V/C, ileus Dysrhythmias Dehydration 2 Ps Diagnosed by serum Ca Nursing care Diagnoses At risk patients S/S of hypercalcemia When to report to MD Medication regimen 2-4L fluids per day unless contraindicated Mobility Safety EKG rhythms

2.8.5. Pericardial effusion Fluid accumulation in pericardial space Clinical manifestations JVD on inspiration (Kussmaul sign) Distant heart sounds or adventitious sounds Cardiac dullness Compensatory tachycardia Dyspnea, tachypnea Chest pain Weakness Anxiety Diagnostics EKG Chest X-Ray CT scan Nursing care VS & pulse ox frequently EKG readings Heart, lung sounds LOC Skin color, temp Labs HOB elevated Patent IV Cough/deep breathe q2 Rest to conserve O2 Supplemental O2 PRN Medical management Pericardiocentesis Radiation/chemo Steroids Diuretics

2.8.6. Cardiac tamponade Pericardial effusion >> compresses heart Keeps ventricles from expanding, emptying in diastole CO falls r/t increasing compression >> Inefficient heart pumping >> Heart failure Similar manifestations, managements to PE Nursing diagnoses Ineffective breathing pattern Fluid volume excess Altered CO

2.8.7. Pleural effusion Pathophysiology Collection of fluid in pleural space >> Dyspnea, pain in chest Can be a complication Heart failure TB Pneumonia PE Cancerous tumors Manifestations Dyspnea Chest pain (pleuritic) Coughing Difficulty lying flat Diminished breath sounds Diagnostics Chest X-Ray Chest CT Thoracentesis* Medical management Thoracentesis Chest tube Nursing care Diagnoses Supplemental O2 as needed Assist in preparation for thoracentesis Lab specimens Chest tube maintenance Pain meds as ordered

3. Sensory Disorders: Visual

3.1. Assessment

3.1.1. Ocular history

3.1.2. Visual acuity OD: right OS: left

3.1.3. External eye exam

3.2. Diagnostics

3.2.1. Direct, indirect opathalmoscopy Cataracts MD office

3.2.2. Slit-lamp exam

3.2.3. Optical coherence tomography Retinal lesions Macular edema Dilating pupils

3.2.4. Amsler grid Macular degeneration >> Grid disturbances

3.2.5. Color vision testing

3.2.6. Indocyanine green angiography Iodine dye N/V ALLERGY

3.2.7. Tonometry Glaucoma Local anesthetic

3.2.8. Fluorescein angiography Non-perfusion Invasive; MD only May turn skin golden for 24 hrs

3.2.9. Ultrasound Retinal hemorrhage or cataracts Tumors Retinal detachment

3.2.10. Perimetry Field of vision Detects scotomas (blind spots)

3.3. Gerontology

3.3.1. Glaucoma

3.3.2. Cataracts 1 or both eyes Loss of transparency Light scattering r/t clumping of proteins Yellow-brown pigment r/t protein breakdown Decreased levels O2 Vitamin C Increased levels Na Ca

3.3.3. Macular degeneration Most common age-related cause in 60+ Drusen (yellow spots) on retina

3.4. Glaucoma

3.4.1. Increased IOP R/T AH congestion >> Damages optic nerve and fiber layer

3.4.2. Leading COB in adults

3.4.3. Risk factors FH Thin cornea AA race Older age DM or CVD** Migraines Myopia Trauma Extended corticosteroids

3.4.4. Stages Initiating events AH outflow system alterations Functional alterations Optic nerve damage Visual loss

3.4.5. Classification Open-angle Primary Normal tension Ocular HTN Angle-closure Pupillary block Occular emergency! Congenital Associational Developemental Corticosteroids

3.4.6. Manifestations Silent thief Blurry vision or halos Focusing issues Poor adjustment to low light Loss of PV Aching HA

3.4.7. Medications Cholinergic mitotics Pupil constriction; AH outflow CSEs Pilocarpine; carbachol Adrenergic agonists Dipivefrin; epi Reduce AH & increase outflow CSEs Education important to prevent systemic Need pressure on lacrimal duct after admin Beta-blockers Decrease AH CSEs Contraindications -lol Alpha-adrenergic agonists -indine Decrease AH CSEs Proper technique Similar to BPH PO meds Carbonic anhydrase -zolamide Decrease AH production Allergies CSE Prostaglandin analogs -oprost Increase uvuloscleral outflow Darken iris & redden conjunctivae May cause rash Report SEs to MD Pressure on site

3.4.8. Surgeries Laser trabeculoplasty AH outflow by widening area Decreases IOP Can cause transient elevated IOP 2-hrs post op Close monitoring Laser irodotomy Pupillary block Contraindicated with corneal edema Trouble seeing in the dark

3.4.9. Nursing management Adherence Medication & administration Support interventions

3.5. Cataracts

3.5.1. Risk factors Age Ocular dx Infection Toxicities Nutrition Physical factors Systemic diseases DM Down's syndrome Subtopic 3

3.5.2. Manifestations No pain Blurry Glare sensitivity Decreased visual acuity Others Myopic shift Astigmatism Diplopia Color shifts

3.5.3. Treatment Surgical only Pre-op care Hold antiplatelet meds Meds as ordered Control HBP before surgery Post-op care Protective measures Don't rub eye! When to call MD

3.6. Macular Degeneration

3.6.1. Nursing management Education Leafy greens, fish Exercise BP, weight HCP appts Ansler grid Supportive care Safety

3.6.2. Risk factors Age Smoking HTN Obesity Hyperopia (map readers) Familial Wet AMD TH & HCTZ use Arthritis

3.6.3. Types Dry Non-neovascular & non-exudative Most common Slow breakdown of outer retina, followed by drusen Wet Abrupt onset* Abnormal BV growth (choroidal revascularization) Chance for fluid, blood leakage

3.7. Low Vision & Blindness

3.7.1. Low vision Nursing management Coping skills Grieving process Spatial orientation Mobility Home health Best corrected vision: 20/70 - 200 Optical and non-optical aids

3.7.2. Blindness Best corrected: 20/400 & no-light perception Braille, computers, guide dogs

3.8. Opthalmic Medications

3.8.1. 1-7% absorbed

3.8.2. Many barriers

3.8.3. Topical preferred r/t local effects

3.8.4. For higher concentration Intraocular injections Systemic meds

4. Sensory Disorders: Auditory

4.1. Assessment

4.1.1. External ear

4.1.2. Otoscopic examination Pearly gray, shiny TM

4.1.3. Gross auditory acuity Whisper Weber & Rinne tests

4.2. Diagnostics

4.2.1. Many types

4.2.2. Audiologist performs

4.2.3. RN assists, educates

4.3. Hearing Loss

4.3.1. Communication techniques Low-tone voice Slow, distinct speech Face-to-face Favor good ear

4.3.2. Types Conductive External Middle Sensorineural Damage to C or V/C nerve Mixed C&S Functional (psychogenic)

4.3.3. Clinical manifestations

4.4. Meniere's Disease

4.4.1. Abnormal fluid collection Malabsorption in endolymphatic sac Blockage of endolymphatic duct

4.4.2. Demographics Men = Women Age 20-60 (40) 50% have family history

4.4.3. Manifestations Fluctuating, progressive HL Tinnitis Pressure, fullness Episodic, severe vertigo

4.4.4. Treatment Low-sodium diet R/T fluid retention 1000-1500 mg/d Avoid high sugar diet Medications Meclizine (Antivert) Tranquilizers Antiemetics (phenergan) Diuretics (HCTZ, triamterene) Surgery Endolymphatic VN sectioning Education

4.5. Vertigo

4.5.1. Disrupted debris in semicircular canal

4.5.2. Caused by trauma or infection

4.5.3. Presents as N/V

4.5.4. Treatment Bedrest Epley maneuver

4.5.5. Meds Antivert (meclizine) Compazine (prochlorperazine)

4.5.6. Vestibular rehab Stress management Biofeedback Vocational rehab PT

4.6. Diagnoses

4.6.1. Anxiety

4.6.2. Risk for trauma

4.6.3. Self-care deficit

4.6.4. Powerlessness

4.6.5. Impaired phys mobility

5. CVA

5.1. Statistics

5.1.1. 3rd leading COD Heart disease Cancer

5.1.2. Leading cause of serious disability

5.1.3. Most common in age 65+ 3/4 of all strokes Risk doubles every 10 yrs after 55

5.1.4. Higher death rates among African-Americans

5.1.5. 2x risk for smokers

5.1.6. Most important risk factor = HTN

5.2. Ischemic Stroke

5.2.1. Pathophysiology Clot >> Ischemia >> Energy failure >> Acidosis + ion imbalance Increased intracellular calcium Cell injury and death

5.2.2. Most common (80-85%)

5.2.3. Nicknames CVA "Brain attack" Urgent like a heart attack

5.2.4. Role of t-PA Revolutionary treatment Narrow, 3 hour window Revascularization of necrotic tissue >> Increased risk for cerebral edema, hemorrhage Many criteria Age 18+ Diagnosed w/ischemic stroke Known time of onset BP < or = 185/110 Assessed via NIHSS tool MCSE: bleeding! Delay invasive lines recommended

5.2.5. 5 types Small penetrating artery thrombotic stroke Most common type (25%) 1+ small vessels AKA lacunar strokes Large artery thrombotic stroke Athero plaques >> Occlusion >> Infarction + ischemia (20% of ischemic strokes) Cardiogenic embolic stroke 20% of ischemic strokes Associations Patho Cryptogenic stroke 30% of ischemic strokes Others 5% of ischemic strokes

5.2.6. Risk factors HTN A-fib Warfarin (INR 2-3) (Aspirin instead of warfarin PRN) Hyperlipidemia DM Smoking Carotid stenosis Obesity Alcohol Periodontal disease Non-modifiable Age 55+ Male African-American race

5.2.7. Manifestation One-sided weakness/numbness Change in LOC Aphasia Visual changes Diplopia Loss of PV (hemianopsia) Dysarthria Aphasia Apraxia Depression

5.2.8. Complications Decreased cerebral blood flow Inadequate oxygenation Pneumonia

5.2.9. Diagnostics Non-contrast cT ECG Carotid ultrasound Other studies MRI, MRA CT Doppler XECT or SPECT

5.2.10. Medications Thrombolytics (t-PA) Anticoagulants Warfarin For A-fib Platelet-inhibitors R/T TIAs Aspirin Clopidogrel (Plavix) Statins Secondary prevention Simvastatin (Zocor) Anti-HTN Secondary prevention

5.2.11. Surgery Carotid endarterectomy TIA, mild stroke Moderate to severe stenosis Complications Carotid stenting High-risk patients Severe stenosis

5.3. Hemorrhagic Stroke

5.3.1. Pathophysiology Bleeding in or around brain tissue Altered brain metabolism Bleeding IICP Secondary ischemia Etiologies Intracerebral hemorrhage** Intracranial aneurysm AVM (esp. in young people) Subarachnoid hemorrhage

5.3.2. Rarer, but more fatal (48% mortality)

5.3.3. Etiologies Primary Intracerebral hemorrhage (CAA) Subarachnoid hemorrhage Others AVM Intracranial (cerebral) aneurysm

5.3.4. Risk factors HTN Cerebral atherosclerosis Alcohol or drug use Non-modifiable Advanged age Gender Congenital malformation

5.3.5. Manifestations Explosive headache Vomiting Early, sudden change in LOC Focal seizure (possibly) Pain & nuchal, spinal rigidity Vision disturbance Tinnitus, dizziness Hemiparesis

5.3.6. Complications Cerebral hypoxia Supplemental O2 H&H Fluids Vasospasms Ca-channel blockers Monitoring 3-14 days after stroke Seizures IICP S/S dehydration Mannitol admin Rebound IICP Hydrocephalus Re-bleeding Hyponatremia 3% hypertonic saline Can be caused by SIADH or cerebral Na-wasting syndrome

5.3.7. Diagnostics Non-contrast CT scan MRI Cerebral angiography LP

5.3.8. Labs PT-INR Platelets PTT CMP Urinalysis Lipid profile

5.3.9. Medications Ca-channel blockers R/T vasospasms Nimodipine (Nimotop) Osmotic diuretic R/T IICP Mannitol Anti-HTN Management Labetalol Nicarpidine Nitroprusside Hydrazaline Stool softeners Straining >> Elevated BP

5.3.10. Surgery Craniotomy Hematoma > 3 cm GCS decreasing Complications Endovascular treatmnet Occlusion of parent artery Obstruction/coil at aneurysm site Complications

5.4. TIA

5.4.1. Temporary neuro deficit r/t impaired blood flow

5.4.2. Warning sign of impending stroke

5.4.3. Need a diagnostic workup

5.4.4. Manifestations Lasts <1hr Sudden loss of M/S/V function

5.4.5. Treatment Platelet inhibitors Aspirin Plavix Ticlid >> Decreased infarction risk

5.5. Nursing Process

5.5.1. Assessment Ischemic LOC Pupils M/S Skin color/temp VS Speech Bowel & bladder fxn Airway, RR Hemorrhagic LOC Pupils M/S Cranial nerves Speech, vision Other neuro deficits

5.5.2. Diagnoses Ischemic Impaired phys mobility Sexual dysfunction Self care deficit Acute pain r/t shoulder Bowel, bladder control Skin integrity Communication Disturbed thought process r/t brain damage Hemorrhagic Ineffective tissue perfusion Anxiety (aneurysm precautions x2) Disturbed sensory perception Acute pain r/t headache