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Parkinson’s: low dopamine. Shuffling gate, decr arm swinging, pill rolling,
tremors at rest
o treatments for intractable tremors
 Deep brain stimulation- improves motor function and reduce
dyskinesia, levodopa and carbidopa, Sinemet. Benztropine to
decrease acetylcholine and tx for tremors
o patient family teaching at home
 promote physical exercise and well-balanced diet. Easy
clothing use, shower bars, raised seats, PT/OT, thickened
liquids and easy to chew foods.
o how to optimize their nutrition
 easy to chew and swallow foods, adequate fiber and fruit to
reduce constipation, 6 small meals a day, small bite sized
pieces,
 limit protein to the evening, this interacts with the Parkinsons
meds
o dysphagia and priority nursing dx
 small bite sized pieces, easy to chew and swallow foods,
proper body alignment, nectar/honey thick, pureed foods.
o how to optimize ambulation safety
 tell them to imagine they are stepping over a line, encourage
a wide gait, use assistive devices,
o Nursing intervention for Parkinson's with pneumonia
 Prevent aspiration, HOB elevated when eating, dysphagia
diet, cough deep breathing
o TRAP
 Tremor, rigidity, akinesia/bradykinesia, postural instability
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Neuro
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Know R/L CVA sx and differences
 R sided CVA: R= reckless!! L side hemiparesis, L hemiplegia,
impaired judgement and time concept, L sided neglect,
visual field deficit, impaired judgement, spatial perceptual
deficit. Impulsive and move fast.
 L sided cva: r side hemiparesis. Speech and language
issues(aphasia). Cautious in making judgements.
Know types of aphasia's
 Wernickes: cant understand
 Broca: cant speak
Characteristics of embolic CVA
 Embolus lodges and occludes an artery.
 SUDDEN onset, body cant develop collateral circulation.
Infarct and edema of area
Usually conscious, may have headache or severe neuro
deficits
 Associated with afib, MI, endocarditis, rheumatic heart,
patent foramen ovale
Cerebral perfusion interventions for ischemic CVA
 2 types if ischemic: thrombotic or embolic
 TPA to be administered within 4 ½ of onset
 BP less that 185/110 and maintain BP for at least 24hrs
 No oral anticoag, if they are, INR has to be less than 1.7
 No recent GI bleed, head trauma within last 3 months,
or major surgery in 14 days
Know what apraxia is
 Loss of movement
 Difficulty with simple tasks like buttoning shirt
Interventions for optimizing communication for post CVA pt
 Speech therapy, simple words, patience, assess for ability to
speak and understand
IV solution for CVA pt with inc ICP, what to avoid for ICP CVA pt
 NO hypotonic solutions(0.45NS) or glucose infusion
 Give hypertonic solution(3%NaCl, 5%NaCl0
Know cerebral artery most commonly effected by embolic stroke
 MCA- middle cerebral artery
Nursing care of patient after cerebral angiogram
 No heavy lifting, fluids, lie still with head flat for 6-8hrs post
angiogram, drink fluids to flush out dye from kidneys
Priority care for emergent CVA
 When exactly sx started, CT within 25 mins, TPA if ischemic if
within 4 ½ hours of onset, cardiac, RR and neuro assessment,
Glasgow coma scale. Watch for hyperglycemia
 Watch for hyperthermia- fever increases brain oxygen
demand and should be treated aggressively
 Anticoags for ischemic stroke in emergent phase is not
recommended due to risk of hemorrhage
 ABC’s!
Dysphagia bedside screening for CVA pt
 Done on all TIA and stroke pts, presence or absence of gag
reflex isn’t enough to confirm. If they fail BDS, repeat in 12hrs
and keep NPO
Difference between TIA vs CVA
 TIA is tiny lack of oxygen, short time and happens suddenly
from microemboli. Warning sign that stroke will ensure in
future
 Temporary loss of neuro function, confusion
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Put on antiplatelet or anticoag, treat hypertension and
hyperlipidemia
 CVA is no oxygen causing long term damage
Risk factors for thrombotic CVA
 HTN, High cholesterol, atherosclerosis, DM, history of TIA,
smoking, birth control
Tx and management of BP in pt with acute CVA vs SAH
 CVA ischemic bp management: meds for BP only
recommended if extremely high-high (>220/120). Pg. 1341 &
p.1339
 Sah management: maintain BP, keep systolic <160
Significance of hyperglycemia and treatment for CVA
 Hyperglycemia provokes anaerobic metabolism, lactic
acidosis and free radical production and increases cell lysis
 Need to treat hyperglycemia aggressively!! This worsens
prognosis
 HYPOglycemia can mimic a CVA
Nursing interventions for hemiparesis
 Dress the affected side first, fall precautions, ROM exercises,
extremities in neutral position and maintain alignment
Definition of homonymous hemianopia
 Can only see half of a visual field in both eyes.
 Neglect the side that they cant see. Rotate plate, scan room
Acute nursing intervention and priorities for emergent CVA
 ABC, manage hyperglycemia
 Establish onset time, complete neuro exam, CT scan STAT
Significance of hyperthermia and tx for CVA
 Worsen prognosis and recovery, give cooling blanket, keep
room cool
 Increases brain oxygen demands
 Incr demands by 6-10% for every degree above normal
Hemorrhagic stroke BP management
 Most important to manage HTN, along with seizure
prophylaxis
Ischemic stroke BP management
 BP meds are only recommended if BP is > 220/120 because
high BP is common- it is a protective mechanism.
 If getting fibrinolytic therapy, bP must be <185/110 and then
<185/110
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Endocrine
o Abnl labs for addisons
 Low sodium and high potassium over 5.0
 Low cortisol and aldosterone
Low glucose
Nursing interventions for graves exophthalmos
 Eye drops, cool compress, tape eyes temporarily closed if
needed
 Salt restriction and elevated HOB- don’t want to incr edema
and swelling
Nursing care and priorities for post thyroidectomy pt
 Watch for signs of bleeding
 Lugols solution to decrease size and vascularity of gland
 HOB elevated, first fluids to be cold or ice chips, may have
voice changes but extreme hoarseness is concerning
 Complete loss of voice and difficulty breathing is an
emergency- notify HCP
 Always have trach/airway at bedside
Sx of tetany
 Uncontrollable muscle spasm, hyperirritability, tingling from
low blood calcium- tx with Ca gluconate
 Result of accidental removal of parathyroid
 #1 sx is tingling around mouth!.
Sx of myxedema & coma
 Low BP, incr susceptibility to infection, constipation.
 Sensitive to anesthesia, barbs and opioids
 Non pitting edema everywhere
Sx of hypothyroid
 Everything is LOW
 Low bp, dry skin, constipation, cold intolerance, sluggish, decr
heart contractility, incr cholesterol and triglycerides
 Labs= HIGH TSH in primary, low T3 T4
Relationship of parathyroid to Calcium
 Parathyroid produces calcitonin which lowers calcium in
bloodstream and is released when calcium is high
Management of Graves disease
 Sx: Tachycardiac, hypertrophy, systolic murmurs, angina,
weight loss, exophthalmos
 Management/tx: RAI(permanent- non pregnant patients),
methimazole and PTU meds
 PTU is TID but methimazole is QD
 PTU works quicker
 Lugols solution: block release of T3 and T4, decreases
vascularity and prevents circulation of T3/T4
 B-blockers- relieves cardiac symptoms
Sx of Cushing's disease
 Moon face, hirsutism, purple striae, pendulous abdomen
 Hyperglycemia, hypokalemia, delayed wound healing
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Relationship of Addison's to Sodium
 HIGH potassium in Addisons
 Low sodium
Relationship of adrenal dysfunction and serum cortisol level
specimen timing
 Cortisol is highest 8 hours after you fall asleep
Management and priorities of Addison's electrolyte abnormalities
 Tx is D5.9 IV fluids,
 6 S's- sudden pain, syncope, shock, super low BP, severe
vomit/diarrhea, serum electrolyte imbalance
Addison's steroid treatment and patient teaching
 Lifelong steroid therapy. Carry emergency kit with IM
hydrocortisone
 Incr stress will result in needing more steroid(surgeries)
 Monitor glucose esp in DM= increases hyperglycemia
 Assess for osteoporosis & weakened immune system
 NEVER stop abruptly= Addisonian crisis with extremely low BP.
Death!
 Lowers potassium and calcium
Addisonian crisis sx
 Hypotension, tachycardia, hyponatremia, hypoglycemia,
hyperkalemia, fever, confusion
Emergent management of Addison's disease
 IM hydrocortisone, and fluids
 Florinef & bydrocortisone
Lab abnormalities for primary hypothyroidism
 High TSH and low T3 & T4
Lab abnormalities for Cushing’s disease
 Androgen excess, hyperglycemia
 High ACTH- stimulates cortisol
 High Aldosterone(mineralcorticoid)- hypokalemia
Surgical treatment for cushings
 Adrenalectomy- can take up to 1 yr for sx to go away
 Nursing interventions: high levels of corticosteroid IV for
several days to balance things out, morning urine
samples for cortisol levels
 Large release of hormones into circulation results in BP
instability, fluid & electrolyte imbalance
Sx and emergent tx for thyroid storm
 Severe tachycardia, heart failure, arrythmias, abdominal
pain, coma
 Hyperthermia is often cause of death
 Tx with meds to block thtroid hormones
RAI therapy and side effects for graves disease
RAI destroys thyroid tissue, usually has delayed response
Need isolation for at least 24hrs
Can develop hypothyroid
Hashimotos abnl labs and what are affected
 High TSH, low T3/t4
 High thyroid antibodies
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Medication tips
o Know Plavix(clopidogrel) MOA and pt teaching
 Inhibit plt activation and aggregation
 Risk for falls, caution with razors
 PTT
o Side effects of corticosteroid therapy
 Incr glucose, delayed healing, susceptibility to infection and
suppressed immune response, hypertension, osteoporosis
o MOA of lugols solution for pt prepped for subtotal thyroidectomy
 Decreases vasculature and decreases bloodflow through
thyroid and therefor decreases T3 T4
 Decreases size to reduce hemorrhage risk
o Dilantin side effects for chronic management
 Anti-seizure for hemorrhagic stroke, for incr ICP
 Side effect is gingival hyperplasia- good oral hygiene
 N/V, hypotension, rash
o Relationship of carbidopa to levodopa & MOA
 Extends half-life. Carbo+levo- Sinemet
 Levodopa is responsible for on + off phenomenon
 Levodopa is the chemical precursor of dopamine and
crosses blood brain barrier and converts to dopamine in brain
 Carbidopa inhibits enzyme that breaks down levodopa
 Doesn’t eliminate tremors, only improves spontaneous
movement
o Side effects of anticholinergic drug Cogentin for Parkinson’s
 Cant see, cant pee, cant shit, cant spit.
 Decreases Ach
 Confusion, palpitations, retention, headache
o Synthroid’s MOA, side effects and lab management
 Increases circulating T4 level and decreases TSH. Increases
metabolic rate, control protein synthesis, CO, blood volume
and boy temp
 Monitor for cardiovascular issues/excitability, too much if not
monitored can make you become hyperthyroid
 TSH- increases. T3/T4 decreases.
o Patient teaching for coumadin
Fall precaution, razors
Vit K is the antidote- Avoid too much vit K
Take 2-3 days to work, 305 days for full effect
Pt 12-20
INR 2-3
Medications and purpose for adrenal insufficiency and postop
adrenalectomy pt
 Adrenal insufficiency= need steroids
 Adrenalectomy- IV steroids for a few days
 Monitor blood sugars, infection, delayed wound
healing, and hemorrhage
Meds and side effects for tx of addisons
 Kaexylate
 Steroids
Emergency med pt teaching for addisons disease
 D5.9 and IV hydrocortisone
 IM hydrocortisone in emergency kit
Thyroid storm cardiac sx and emergency med tx
 Severe Tachy, life threatening arrythmias
 Beta blockers, antithyroid meds, fluids, cool down, Tylenol for
temperature
TPA contraindications and lab ranges
 BP cant be over 185/110 and not taking anticoags. IF they
are, INR <1.7
 Needs ot be before 4.5 hrs of onset of sx.
 No head trauma, MI in past 3 months, no major surgeries in
past few weeks, platelets over 100
Relationship of glucocorticoid response in post adrenalectomy pt
 Nizoral: prevents rise in ACTH secretion in cushings
 Steroids prevent risk of going into Addisonian crisis
Medication tx for initial management of hyperthyroidism
 PTU & methimazole, iodine
 Can be on beta blockers
Medication tx for TIA
 Antiplatelet(Plavix), anticoag(coumadin/warfarin),
anticholesterol(statin), antihypertensives(-olol)
Pt teaching for anticoagulants
 Fall risk, razors, avoid too much vit K
Memorize heparin and coumadin therapeutic lab ranges
 PTT 60-100 (Unfractioned Heparin)
 PT 12-20 on Warfarin. If not on it, nl is 30-45 sec
 INR 2-3 on coumadin or <1 NL
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Agnosia: inability to recognize object by sight touch or hearing
Apraxia: inability to carry out learned movements on command