56

N242
Objectives
By the end of this learning experience, the student will be able to:
1.
2.
Differentiate between morality and ethics
Discuss contemporary bioethical issues.
.
3.
4.
5.
6.
7.
8.
9.
Explain advanced directives
Explain the ANA and how it relates to ethical decision making.
code of ethics.
State problem solving methods which can be utilized for ethical decision making.
Evaluate the Patient’s Bill of Rights and it’s impact on nursing care.
Compare and contrast deontological and teleological theories.
Define key ethical terms.
Participate in a mock ethics committee; determine an ethical case outcome based
Upon theoretical principals.
Critical Thinking Activity: Your patient is dying. He has morphine 2-6mg/IV q 2 hours for pain. His wife pleads with you to give him the maximum dose of morphine. The patient is resting comfortably, is quite sedate and in no obvious discomfort. His respiratory rate is 10 breaths per minute and his breathing pattern is slightly irregular with an occasional grunt and 1-2 10 second periods of apnea. How would you handle this situation?
57

Principles of Problem Solving……
1. Assess


Is the situation indeed an ethical problem?
Are there conflicts (i.e., decision making between parties) involved?

Identify significant people involved
2. Planning

Gather important information; medical records, legal data, cultural values, religious beliefs

Separate facts from beliefs

Is the patient competent to make decisions?
 Identify everyone’s moral/ethical issues
3. Implementation; work within the framework of the theoretical perspective you have been assigned.
Utilitarian

Predict the consequences to the alternatives

Assign a positive or negative value to each consequence
 Choose the consequence that predicts the “greatest good for the greatest number”
Deontological

Identify the pertinent moral principles

Compare alternatives with moral principles

Apply the highest level moral principle if there is a conflict – apply the “golden rule”
4. Evaluation

What is the best or ethically correct action?
 Give the ethical reasons for your group’s decision
 State the ethical reasons against your group’s decision
Respond tot the reasons against your group’s decision
58

THEORIES
• TELEOLOGICAL: AKA Utilitarian
– “The greatest good for the greatest number of people
”
In the right to life debate, this would be linked to those who believe in the right to choose
• DEONTOLOGICAL
– “The Golden Rule” In the above debate, this would be reflective of the view point right to life
TERMINOLOGY
– Ethics
– Morality
– Autonomy
– Beneficence
– Nonmaleficence
– Paternalism
– Veracity
CONTEMPORARY BIOETHICAL
ISSUES
• PERSONAL ETHICS
• MEDICAL/SURGICAL: PATIENT RIGHTS
• LIFE AND DEATH ISSUES
THE NURSES ROLE IN DEALING
WITH ETHICS
• Use the ANA code of nursing ethics
• Know your beliefs and choose the right agency
• Dealing with Advanced Directives
– What does your patient know???
ETHICAL ANALYSIS
• Refer to your syllabus at this time
• Review the case study handed out in class
• As a group determine the outcome of this case study based on your prospective;
Utilitarian or Deontological
• Discuss your group’s conclusion in class
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
59

1.
2.
3.
4.
5.
N 242
SYSTEMS THAT SUPPORT DELIVERING QUALITY CARE:
NURSING SERVICE DELIVERY PATTERNS, PATIENT CLASSIFICATION SYSTEMS, AND
JOB CLASSIFICATIONS
Objectives
By the end of this learning experience, the student will be able to:
Compare and contrast different types of nursing service delivery patterns.
Describe how classification systems are used to identify patient needs and allocate nursing resources to meet them.
Evaluate how the patient care environment is impacted by the above concepts.
Describe the concept of shared governance.
Identify the key concepts related to Continuous Quality Improvement.
Critical thinking activities:
Activity #1: Identify the specific pattern of nursing service delivery system used on the unit to which you have been assigned. How is it consistent or in conflict with the agency’s formal organization?
Activity #2: Access a copy of your agency’s organizational chart. Bring it with you to class. Try to answer the following questions in relation to the organizational chart: a. Following the concept of the chain-of-command and you selecting the key issue, how many levels must be used to resolve the key issue? (For example, if a staff nurse wants to make a vacation request, what needs to occur? If the nurse manager wants to purchase a new piece of equipment under $300.00 (or over $500.00), what needs to occur?
CASE STUDY
Gary is a 44 year old quadriplegic. He was admitted yesterday and underwent a shunt revision.
Gary has endured several of these procedures over the years and is well known to the staff. He is on two antibiotics (IV QID and TID) along with several PO med.s (administered 3 times during the day shift).
Gary also needs to have a special bed bath due to poison oak (his dog jumped on his lap and rubbed all over his torso and legs after rolling in the weed). Keep in mind Gary is unable to move any extremities, only shrug his shoulders and turn his head. He requires total care with both personal hygiene and all ADLs including needing to be fed. He is on a bowel regimen and uses a condom catheter. Gary is pleasant, has an excellent sense of humor and is patient. His vital signs are WNL, his dressings are dry with old drainage.
1. Using the above case study and the patient classification sheet delivered in class, figure out the acuity # you would give to Gary.
2. What care could you delegate to the CNA? LVN? RN?
60

QUESTIONS TO ASK
YOURSELF
• What type of Nursing Service Pattern is your unit comprised of?
– Team, Case Management, Primary or ??
• What does your agency’s organizational chart look like??
• How would you make a change at your agency? What is the chain of command?
What is the organizational climate at your agency?
• You have all rotated to different hospitals and agencies …what was the “feeling” you experienced working with the staff?
• The organizational climate supports nursing, staff and patients
What makes up the climate?
• What is a philosophy?
• Philosophy and mission statements
• Departmental philosophies
• All agencies have policies and procedures …you will need to know these for your chosen agency
• Together: Philosophy, policies and procedures = Quality Care
CONTINUOUS QUALITY
IMPROVEMENT
• In order to maintain our quality care…
• CQI is providing services that consistently produce desired results or outcomes
(audits, inservices, review of unusual occurrences)
• Perspective on agency quality comes from
– Patients, community
– Staff
– Agency
CONTINUOUS QUALITY
IMPROVEMENT
• Components of CQI
1. Structure: staffing patterns, patient demographics; bottom line, satisfy your staff and the consumer
2. Process: In order to define and provide a structure for CQI, a process is necessary
– Survey of staff and community satisfaction
– Evaluation of the unusual occurrences and policies in place
CONTINUOUS QUALITY
IMPROVEMENT
1. Outcomes: Evaluate both positive and negative results of surveys, policies etc..
Compare results of data collection with cost effectiveness
61

CONTINUOUS QUALITY
IMPROVEMENT.. Some last words
• This is a 24 X 7 commitment
• It is important for the staff to relate to and facilitate the agency philosophy and mission
• Agency needs to involve staff in CQI
ORGANIZATIONAL CLIMATE
• Remember it is BASED UPON:
– Philosophy and mission of the agency
• May have more detailed philosophy and mission statements on individual units
– Procedures and standards of care
• Adapted from ANA standards
– And other key parameters (see next slide)
• Allows nurse to grow in the role; preceptorship
• An environment that nurtures professional and personal development
• An environment that encourages highest productivity, deliver efficient services, maintains quality care
• Positive interactions
• Staff participation in organizational decisions and functions
• Committed staff
• Reciprocity among nurses and teams
• Stress and tensions surrounding nurses work are reduced
ORGANIZATIONAL CLIMATE continued
• ORGANIZATIONAL CHART
– Centralized vs. decentralized
– Demonstrates chain of command
American Nurses Association – Nursing
Survey 1/01
•7,299 respondents (online survey), with an age range between 41-60 years old
(majority will retire within the next decade)
•75% believe that the quality of care in their facility has declined over the past 2 years
•56% believe they have less time available for patient care
•more than 40% feel uncomfortable with the thought of having someone they care for
(family or friend) being hospitalized
• 54% would not recommend nursing as profession to their children or friends
• 5,067 nurses responded inadequate staffing is the chief way in which quality of care has declined
• ANA study on staffing (March 2000) found a direct correlation between better patient healthcare outcomes with higher staffing levels and higher staffing mix
62

RECOMMENDATIONS OF THE
ANA 2001 SURVEY
• Restrictions on mandatory overtime
• Increased whistleblower protections
• Mandated collection of workforce and nursing-sensitive data (CQI with a nursing emphasis)
• Patient classifications systems
UCSF RESPONDS TO THE
ANA SURVEY
• “Nursing profession must be reinvented to ease personnel shortages ”
• Not a cyclical shortage that can be
“fixed” with increasing wages or increasing nursing programs
• The aging workforce + better opportunities for women + chaotic health care system = chronic nursing shortage
SUGGESTIONS FOR workforce
IMPROVEMENT
• Nursing needs to “reposition itself” and provide an improved image
• Improve the nursing work environment
– Better leadership/union partnerships
– Engage RNs in organizational decisions
– Invest in retention of nurses
SUGGESTIONS FOR
IMPROVEMENT in education
• Increase the non-white and male student populations
• Make education more accessible
(evening/weekends)
• Ensure clinical experiences are reflective of the demands made upon the new grad.
SHARED GOVERNANCE
• What is it?
– When members of a work force (staff) have a greater input in the decision making process of the work area (unit)
• Can be a “loose term” as the degree of
“sharing” varies
• May be implemented throughout the organization or on a specific unit
SHARED GOVERNANCE
• How to establish shared governance
– Agreement with management
– Form a committee; determine times/places to meet
– Define the term S.G. and degree of S.G.
– Outline a plan (approx. 1 year)
– Implement
– Evaluate after one year
– Modify and actualize the plan
63

NURSING DELIVERY
PATTERNS
• CASE METHOD
– Private duty nurses
– Nurse:Patient; Nurse:Family
– Direct pay from client to nurse
– Originated in the tenements of large cities
– Still Around?
• FUNCTIONAL NURSING
– Military
– Medical model, based on the treatment of disease
– Delegated tasks
– Around today?
• TEAM NURSING
– Skill mix
– Changes daily and by shift
– First started with an RN shortage
– Came about again with agencies implementing cost effective measures
– Will it go away…or stay?
• PRIMARY NURSING
– An attempt to make nursing a profession
(one license)
– Used when agencies intend to reflect a more professional staff
– May come about due to regulations and more complex patients
– Evolved in the early ’80s, resulted in LVN and CNA layoffs
– Provides total care for 3-4 patients
– RN develops the care plan to reflect 24 hour care
– What’s the outlook on this method?
• CASE MANAGEMENT
– In the past, social worker’s role
– Now, a nursing role
– Mediator, negotiator, coordinator of patient care
– Client’s needs are paramount
– Coordinates with other disciplines involved in meeting the clients
’ needs
– Usually BSN prepared
– Practiced in home care nursing; are you able to do this as a new graduate?
PATIENT CLASSIFICATION
SYSTEMS
• Do we staff by acuity or census?
• Patient acuity = patient care hours
– Assesses the amount of time required to deliver patient care
– Identifies what type of nursing care is needed (i.e., total care vs. assisted)
– Used to calculate the number of staff and skill mix
64

PATIENT CLASSIFICATION
SYSTEMS
• We need to look at both census and acuity
• New California laws
– Acuity system (became law, then aborted)
– “Licensed” Nurse:Patient ratio
• Problems with the acuity system?
• Look at the case study and determine the acuity
PATIENT CLASSIFICATION
SYSTEMS
• Acuities are measured either daily or by shift
• Assessed and updated by the RN, usually
• Can this measure quality care?
65

N 242
Objectives
By the end of this learning experience, the student will be able to:
1.
2.
3.
4.
Define managed care.
Differentiate between HMO, PPO and IPAs.
Evaluate time management techniques/time saving techniques.
Implement principles of priority setting that staff nurses use when managing care of a group of patients.
Differentiate between clinical (AKA critical) and patient pathways. 5.
6.
Compare the payment options for health care services.
Critical Thinking Activity: Complete the following....
I am _____an early riser, _____ a night owl.
I best use my ____left brain, ____right brain, ____both, ____do I have one???
My living environment is ____clean and orderly, ____could use some help,____is equivalent to the remnants of an 8.5 earthquake
My phone has ____an answering machine, ____ call waiting, ____never been put down long enough to collect dust, ____no answering machine, ____been put away in storage.
I ____do, ____do not have a problem saying, “no”
I ____am, ____am not a procrastinator.
66

DEFINE AND DISCUSS
• HMO
• PPO
• Universal health care
– Access
– Rationing?
• Managed care
– Prevention
– Cost containment
OVERVIEW: HEALTH CARE
• Priorities for improved health
– Health promotion ; exercise, diet, + coping, ↓school violence
– Health protection ; helmets
– Health prevention ; immunizations
• Who pays for health care?
– May be private, public or paid insurance plan
• Past = retrospective
• Present = prospective
OVERVIEW: HEALTH CARE
• Median age of US citizens = 36 y/o
• 13% population is over 65 years
• Health problems we are facing
– Geriatrics
– Cancer
– Diabetes
– HIV
– Environmental/occupational safety
– Drug abuse
DEFINE AND DISCUSS
• IPA
• Capitation
• Gate keeper
– Your future role?
– Advanced practice
REVIEW THE ANA POSITION
STATEMENT ON HEALTH CARE REFORM
• All citizens have equitable services
• All citizens will have primary health care services
• Consumers must be the central focus of the health care system
• Consumers must be guaranteed direct access
• Consumers must assume responsibility for their health
REVIEW THE ANA POSITION
STATEMENT ON HEALTH CARE REFORM continues …
• Health care services must turn from treating the illness to promoting wellness
• Health care must be delivered through efficient use of resources
• A standardized package of health care finances; public and private
• A plan to protect against catastrophic costs
67

AHRQ (the Agency for Healthcare Research and
Quality ) Data Show Rising Hospital Charges,
Falling Hospital Stays
Press Release Date: September 18, 2002
• New technologies and rising medication costs explain much of the increase in average hospital charges, while economic pressures have contributed to shortening the average patient stay for most conditions.
• Example: Stroke (acute cerebral vascular disease)
—from $15,365 to $19,956.
Average hospital stays fell from 9.5 days to
6.7 days.
Who is making the money in health care?
From the Institute of Health and Socio-Economic Policy report (12/2005):
• Drug companies: The world’s 13 largest alone recorded $62 billion in profits in 2004.
• HMOs: The 20 largest in the U.S. made $10.8 billion in profits in the most recent fiscal year.
• Hospitals: Aggregate profits for U.S. hospitals reached a record $26.3 billion in 2004 – and profits have risen substantially the past few years even as the number of hospitals and hospital beds has been shrinking.
• Executive compensation: 12 top HMO executives pocketed
$222.6 million in direct compensation in the most recent fiscal year. The top 12 drug company executives collected
$192.7 million for the same period.
• Mergers: $1.15 trillion has been consumed by pharmaceutical, hospital, HMO, medical device, and biotech corporate mergers and acquisitions in the past 12 years.
Who is making the money in health care?
From the Institute of Health and Socio-Economic Policy report (12/2005):
• Executive compensation: 12 top HMO executives pocketed $222.6 million in direct compensation in the most recent fiscal year. The top 12 drug company executives collected
$192.7 million for the same period.
• Mergers: $1.15 trillion has been consumed by pharmaceutical, hospital, HMO, medical device, and biotech corporate mergers and acquisitions in the past 12 years.
One last item about the cost of hospitalization (healthcarefees.com)
• Private room (just the room, not supplies or the nursing care):
– Low end price $ 795/day
– High end price $ 1,685/day
• An Aspirin
– Low end price, $0.25 each
– High end price, $5.00
• Know your own personal time management style; how do you organize at home? Can you implement those strategies in your career?
• ORGANZIZE and PRIORITIZE
– Yourself
– Environment
Organizing yourself and your environment **
• Start at home
– Set goals
– Make lists
– File
– Remove clutter
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Priorities! **
• After organization…Prioritization
• Priority Ranking of Individual Needs
– First Order: an immediate threat to the patient
’s survival or safety
– Second Order: Actual problems for which the patient or family have requested immediate help
–
Third Order: Actual or potential problems that the patient or family does not realize
–
Fourth Order: Anticipated actual or potential problems with which the patient or family will need help in the future
MANAGING OTHERS**
• DELEGATION
– Interpersonal communication
• Starts at the beginning of the shift
• Continues throughout
• Ends with a “Thank You”
– Gain and maintain respect
• UAP
– Defined
– Appropriate assignment, give information and keep the line of communication open
EQUIPMENT AND SUPPLIES
• Do you know how much it costs
• Wasting
• Stealing
• Disposable
• Dated materials
And now a word about Evidence – based Practice (EBP)
• Defined: involves the integration of research and other best evidence with clinical expertise and patient values in health care decision making (Sackett et al., 2000)
• Translation: Implementation of scientific research into practice
• Best Practice: A new nursing “buzz” word that can have rather elusive meanings
– The goal of Best Practice is to apply
“the most recent, relevant and helpful nursing interventions in clinical practice (John A. Hartford Center of Geriatric Nursing Excellence, 2001)
So, what does this mean??
• Be prepared to participate on unit/hospital based committees in which you may …
– Be involved in a process that focuses on nursing/medical research to promote standard policy and procedures
– Help to develop new policies and procedures based on data collected within the organization and/or research published
PATHWAYS TO EFFICIENCY
AND EFFICACY**
• Clinical pathways
– Definition
– Benefits and Problems
• ↓ patient stay
• ↓ hospital / patient costs
• Utilizes more case management
• Identifies and helps to order proper activities
• Sequences activities of multiple disciplines
• Defines time estimates for procedures and tests
69

• Problems with Clinical Pathways **
– Success depends upon the collaboration between medical, nursing and other disciplines
• Patient pathways **
– Definition
– Empowers your patient
• Incorporates education
• Pt is more responsible
• Moves patient from sick role towards selfcare
• Gives patient information about their diagnosis
• Allows for more adult-adult relationship between primary provider and patient
70

Objectives
By the end of this learning experience, the student will be able to:
EFFECTIVE COMMUNICATION
7.
8.
9.
10.
11.
1.
2.
3.
4.
5.
6.
Identify the areas where the RN uses communication skills
Name the order of the transcription process.
Determine what patient is in most need of a patient care conference.
Differentiate among successful strategies to handle conflict resolution.
Identify the factors needed for effective communication.
Discuss ways to effectively communicate with staff members of varying degrees.
Explain the key concepts of delegation; five rules and five steps
List the essential requirements of the RN in the role of supervisor.
Compare the roles of licensed personnel vs. unlicensed personnel.
Compare and contrast the role of the LVN vs. RN.
List the key factors related to becoming an effective supervisor.
Critical thinking activity:
Activity#1: List several different situations where a nurse must employ effective communication strategies in person and in writing.
71

Introduction
• What is communication?
• What are the components of communication?
• What statements facilitate communication?
• What statements obstruct communication?
THE NURSE COMMUNICATES
• Expectations of professional behaviors and higher level communication skills
• It is up to you, the RN
• Areas where RN communication skills are essential
– Report
– MD orders
– Patient care conferences
– Giving feedback
– Other areas?
Where are RN Communication skills found?
• Receiving and giving report
• Using the telephone (electronics) to access information
– Similarities and differences in transferring information in person vs. electronics
• Physician orders
– Defined: Prescriptions that are carried out by a health care worker
– Orders must clearly indicate what needs to be done, to whom , how and when. Essential components: dated, timed, what the plan is, when and how the order is to be carried out
More RN Communication skills
• Transcription Process
– Read the order
– Collect forms
– Complete the requisition form (i.e. labs, therapy)
– Transcribe the order on the necessary document
(kardex, MAR)
– Place a telephone call if needed to enhance the order
– Sign off the order according to agency policy
(date, time and name) ** This is the point where the RN agrees to carry out the order
More RN Communication skills
• Patient Care Conferences
– Who “fits the picture” for a conference?
• Language or communication barriers
• Extremes in chronological age
• Complexity of disease process
• Staff unfamiliar with treatment approaches
• Unusual patient coping styles (“difficult” patient)
• Lack of social or economic report
– These days, all patients’ progress are reviewed during the multidisciplinary conferences at most agencies
More RN Communication skills
• RN’s give feedback about performance
– LVN
– UAP
– New Grads
• Any other areas that require the RN to communicate???
72

CONFLICT IS POSITIVE
• Allows an opportunity to communicate professionally, mediate, negotiate and resolve
TERMS
• Found in your Wywiolowski text
– Conflict
– Constructive conflict
– Destructive conflict
– Intrapersonal conflict
– Inter group conflict
– Intra group conflict
• Etiology and symptoms
MORE ON CONFLICT
• Identify situations that inspire conflict in health care
• Guidelines to deal with conflict (from W.)
– Separate facts from opinion
– Identify the specific problem
– Seek suggestions from those involved
– Select the solutions that settle the disagreement
– Note the consequences of not sticking to the agreed solution
– Evaluate your success in resolving conflict
Effective Communication and the Art of
Delegation and Supervision
• First, let’s look at the current Health Care
Environment
– 97% of U.S. Hospitals use unlicensed care givers
– The RN is the MANAGER OF PATIENT
CARE
– New graduates must have the tools and skill set to supervise and delegate
DELEGATION
• “Is the entrusting of a specific task or project by one person to another ”
• RN delegates to subordinates
– Know the patients’ acuities
– Know the licensed staff and their scope of practice
– Unlicensed – specific job description
TERMS ASSOCIATED WITH
DELEGATION
• Trust and time
• Delegator
• Delegatee
• Policy and procedure
• Responsibility
• Authority
• Accountability
• Competence
73

Five Rules
1. Delegatee must be available and permitted
2. Skills must match the demands of the task
3. If numerous tasks, then spread among delegatees
4. New employees must learn thier roles
5. Complex and/or time-consuming tasks must be delegated to two or more individuals
Five Steps of Delegation
1. Goal Setting
RN and subordinates
2. Communication
“A two way street”
3. Motivation
Using praise
Constructive feedback
Building on other
’s strengths
Five Steps of Delegation continues
4.
Supervising (this is you in about 6 months!!)
Take a look at yourself
Understand the agency; culture, policy and procedure, job descriptions
Understand your co-workers
Teach others
R*E*S*P*E*C*T
Role model
Maintain a supportive attitude
Five Steps of Delegation continues
5. Evaluating
Accentuate the positive
Use constructive criticism
Discuss issues in private
Adhere to standards of care and evaluate against these
Reinforce positive behaviors
Follow through
Legality of Delegation
What circumstances put the RN ’s license in jeopardy???
74

N 242
LEADERSHIP PRESENTATION OF SELF IN PERSON AND WRITING
Objectives
By the end of this learning experience, the student will be able to:
1.
Evaluate key elements of presentation of self; personal development
2.
Discuss the importance of aligning the job seekers philosophy and goals with the prospective agency.
3.
Outline the necessary tasks in preparing for an interview
4.
Implement key steps in seeking employment in nursing by specifically developing a sample cover letter for a job application and writing a resume.
5.
Explain the difference between a cover letter and resume`.
75

PERSONAL DEVELOPMENT
• Define your philosophy and goals
– Why am I looking for this particular nursing position?
• Income? Relocation? Challenge?
Responsibility?
– What am I expecting?
• From the patient care assignments
• Working with peers
– Set Goals
1. Graduate
2. Take NCLEX
3. Job Search
Matching Future Employers with Your
Career Goals
• Things to consider…
– Location
– Work activities
– Stress
– Autonomy vs. authority
– Benefits
– Opportunities for growth/career ladder
– Recognition
– Human relations
Developing Yourself as an Entry
Level Professional
• Develop a sound and solid knowledge base (doing this now!)
• Continuing with your education
• Embrace the nursing process
– Use this process … even when managing others
• Bottom line – maintain standards always
Presentation of Self
In person …preparing for the interview
• Before the interview
– Ask yourself…is this an institution I want to work for? Are my philosophy and goals aligned with the institution?
– Develop a perfect and complete resume`
– Where professional clothing – suit yourself !!
Before the Interview .. continued
• Professional Attire
• Keep your hair out of your eyes
• Do not “over – do” the make-up or jewelry
• Remove the nail polish
• No perfume or aftershave
• One last check in the mirror…do you look like someone the manager would like to hire???
The Interview
• BE ON TIME
– Allow for plenty of time to get there; anticipate traffic and parking
– If you smoke…don’t before the interview
• Bring important documents
– Nursing license (if you have it)
– Driver’s license
– Immunization record
– Social Security #
– CPR/BCLS
• Have a prepared reference list with current phone #s, addresses, email address (2 copies; one for the manager and one for human resources)
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The Interview … continued
• Bring a Criminal Background check (if you have it)
• Fingerprints on record?
• Be prepared for a drug test (urine or otherwise)
• Anticipate questions (see hand-out)
– Practice with someone before hand
• Prepare questions for the interviewer
Follow Up
• Personal Note…thank you
– Indicates interest and thoughtfulness…could leave the employer with a favorable image
– Send it immediately
– Focused but friendly
– Thank the interviewer for her/his time and consideration
– Indicate how you can help meet the challenges of the unit
– Ask for the job!
• Haven’t heard back? Place a call
Developing a Resume`
• Resume` types
– Chronological
• Highlights education and work experience
• Rank from present to past
– Functional
• Highlights Specific Job “duties”
• Includes work experience
– Combination
• A blend of both types
Resume` Writing the Best One
• A resume` states “ only the facts ”
• Includes ; goals, experiences, education, pertinent personal data (your name and way to contact you)
• Goal/Objective; can be specific or broad
• Experience:
– Position, title, describe duties
– New skills learned, specific accomplishments
– Recognition awards, special courses
Resume` Writing the Best One
• New Grads
– Clinical experiences; highlights only, special projects
– Any awards or honors
– Part-time or summer employment
– Service organizations – community service
(community involvement), NSA (leadership)
• Best advice? Get a book or go online!
The Cover Letter
• One page
• Introduces you to the potential employer
• Use Key Words (i.e., leader, creative, team player)
• Show cases you, your background, why you are best suited for the job
• This is where you can specify an area of interest, while leaving your resume` to portray where you have been and what you have been doing
77

N242
THE TRANSITION: REALITY SHOCK
Objectives
By the end of this learning experience, the student will be able to:
1.
Define the term reality shock.
2.
Differentiate the phases of reality shock.
3.
Explain two ways to resolve reality shock.
4.
Identify 3 ways to decrease personal stress as a new graduate.
Critical Thinking Activity: Prepare questions for guest speakers
78

REALITY SHOCK
• Definition:
– A term used to describe the reaction experienced when one moves into the work force after several years of educational preparation (Zerwekh & Claborn, 1994)
PHASES
• Honeymoon
– Excitement. Perceptions feel unreal and distorted. All is Wonderful! Usually short lived. Realizes things aren ’t done like you learned in school. Begins to identify personal style.
PHASES
… continued
• Shock – Rejection
– Feeling like a failure, Increased concerns over feelings of minor pains and illness.
Fatigue and lack of energy. Feels like a failure. Mistrusts. Bands together with other new graduates. Hypercritical
PHASES
… continued
• Recovery … thank goodness!!
– Sense of humor comes back. Less tense about going to work. Objectively evaluates the work setting. Increased competence
When does this transition from student to the reality of nursing begin??
• As a Novice
– A novice is a new graduate nurse or a nurse who is in a new setting (i.e., clinical nurse
→ instructor)
Will I Survive??
• YES… if you
– Develop positive thinking (AFOG)
– Be flexible
– Get Organized!! (check lists and delegate appropriately)
– Stay Healthy…exercise!
– Identify a MENTOR
– Relax – do fun things!!
– Realize your role – clarify expectations with your supervisor (preceptor, mentor)
79

1. Name the three meninges, their location in the CNS and primary function.
2. Differentiate between astrocytes, glia cells and Schwann cells.
3. What is the relationship between the choroid plexus and arachnoid?
4. Describe the characteristics of normal CSF fluid.
5. State the purpose of the blood-brain barrier system.
6. How does blood leave the brain…discuss the pathway of venous drainage.
7. State three functions of the following lobes:
Frontal
Temporal
Parietal
Occipital (state only one function)
8. The patient’s retilcular activating system is malfunctioning. What are your assessment findings?
9. The patient’s deficits are ipsilateral. Where would you expect to find dysfunction?
10.The patient has Parkinson’s disease, what neurotransmitter is deficient?
11.The patient can not understand the spoken words of others and is assessed to have expressive aphasia.
The location in the brain is known as ____________________area.
12. Differentiate between supratentorial and infratentorial.
80

13. The patient has a problem with proprioception, what is that? What area of the brain controls this?
14. The patient’s Corpus Callosum was severed. What would be the outcome?
15. What is the homunculus (hint: It is not a troll)?
16. The patient sustained a neck injury at the C4 level where the spinal cord is severed.
What would you expect to find in terms of deficits?
17. Discuss the clinical manifestations of an upper motor neuron problem vs. a lower motor nerve problem?
18. Differentiate between a two neuron reflex arc and a three neuron reflex arc.
19. Review cranial nerves. Describe the function of cranial nerves III, V and VII.
20. The patient is experiencing left eye has ptosis. Which cranial nerve is involved? Does it involve the left side of the brain or the right?
21. Which part of the autonomic nervous system is activated when you are being chased by a green-hairy monster? Describe your signs and symptoms.
24. The patient has a condition called acromegaly in which his __________ gland is secreting excessive growth hormone. Describe how the negative feed back loop is disrupted.
25. The patient had surgery on his pituitary gland. He is 1 day post-op and is experiencing diminished peripheral field vision. Explain why.
81

REVIEW OF THE NEUROLOGICAL SYSTEM
1.
By the end of this learning experience, the student will be able to:
1.
After completing the assigned review sheet, be able to answer the basic questions provided.
2.
Explain the various diagnostic tests available to the neurological patient.
3.
Describe increased intracranial pressure (ICP); pathophysiology, clinical manifestations and therapeutic interventions.
4.
compare the classifications of brain herniation.
5.
Delineate important nursing assessments and interventions for a patient with increased ICP.
6.
List the common diagnostic tools used to identify neurological disorders: CT, MRI, Angiography,
PET, SPECT, EEG and Lumbar Puncture.
7.
Discuss the patient preparation and after care of the above diagnostic tools.
Increased Intracranial Pressure
Critical Thinking Activity
Complete the chart below regarding the clinical manifestations of increased intracranial pressure.
CLINICAL
MANIFESTATIONS
Widening pulse pressure
NURSING INTERVENTIONS
Decreased pulse
PATHOPHYSIOLOGIC-AL
BASIS
Cardiac dysrythmias
Headache
Seizures
Adapted from Beare/Myers Adult Health Nursing (1994)
82

Diagnostics
•Radiography (X-ray)
–Older diagnostic tool. Demonstrates problems with the bony structures.
•Computed tomography (CT)
–QUICK diagnostics. Radiographic.
•Position Emission tomography (PET)
– an imaging procedure showing the chemical function of an organ or tissue rather than its structure.
More diagnostics
• Single Photon Emission Computed Tomography
(SPECT)
– providing information about blood flow to tissue
• Magnetic Resonance Imaging (MRI)
An MRI image shows all the structures in great detail, like you have opened up the body to have a look.
MRA
– use of MRI technology that produces well-defined images of blood vessels without the risks associated with standard angiograms.
Yet …even more!
• Angiography
– Arterial study of the cerebrovascular system
• Electroencephalogram (EEG)
– Seizure activity
• Lumbar Puncture
– Evaluation of CSF; infection
Increased Intracranial Pressure
• ↑ ICP is the result of a balance between the components of the cranial vault. The cranium allows little room for expansion. When there is an increase in the volume of one of these components and the brain can no longer compensate, the result is increased ICP.
• Compensatory mechanism failure.
Causes ischemia → hypoxia → herniation → brain death.
• Increases in tissue or….
• Increases in blood volume or….
• Increases in CSF volume or….
• Other causes
Clinical Manifestations
• Early Signs:
– ↓ LOC (restlessness, confusion, lethargy)
–
Pupillary dysfunction
–
Motor weakness
– Sensory deficits
–
Cranial nerve palsy
– Possible H/A
–
Possible Seizures
83

Clinical Manifestations
• Later Signs:
– Continued deterioration
– Possible vomiting
– H/A
– Hemiplegia, decorticate, decerebrate
– Altered V.S.
– Respiratory irregularities
– Impaired brain stem reflexes
The brain will try to compensate
• Cushing’s response
– ↑ systolic pressure
– Widening pulse pressure
– Bradycardia
• Cushing’s Triad… last ditch effort to compensate
– Hypertension
– Bradycardia
– Abnormal respiratory response
·
·
·
·
·
No more compensation? Then expect herniation
• Herniation
– Definition: Displacement of a portion of the brain through or around linings of the brain or openings within intracranial cavity. Results in compression, laceration, distortion or necrosis of brain structure.
Classification:
Supratentorial
Uncal
Transtentorial or Central
Infratentorial
Extracranial
The patient returns from CT, the diagnosis is
Hydrocephalus - How would you intervene …
• Fluids?
• IV?
• Medications?
• Specify the nursing interventions that avoid further increases in ICP
↑
Diagnostics
ICP Monitoring
Nursing Interventions : astute assessments and observations
84

N242
By the end of this learning experience, the student will be able to:
1. Explain the nursing considerations when conducting a neurological exam.
2. Obtain relevant subjective information from a patient with a neurological disorder.
3. Using correct technique, examine the patient and attain appropriate objective information about the neurological system.
4. Compare abnormal from normal subjective and objective findings related to the
1. neurological system.
5. Explain the etiology of Deep Coma.
6. Discuss the rationale for using a coma vs routine neurological assessment
7. Using correct technique, examine a patient in a deep coma.
.
Critical Thinking Activity
How would you assess the following areas? (Be specific)
Occulomotor nerves facial nerves
Olfactory nerves
2.
Describe the Glascow Coma Scale:
85

Neurological Assessment
Who does what?
MD = diagnosis of disease
RN =
•Collects data
•Identifies special areas of concern
•Potential nursing diagnoses identified
•Information is valuable to subsequent care givers
• Major life threatening – ER/ICP
• Screening – Admission –maybe only spinal involvement
• Comprehensive – Admission – full exam
• Consider the Environment; no distractions, privacy vs. involving significant other
• Tools; Pen light, reflex hammer, cotton swabs, tongue depressor, …. See your syllabus!
• History; An important tool in sequencing the events; maybe important to have the significant other ’s opinion
OTHER SIGNS AND
SYMPTOMS
• VITAL SIGNS !!
• Respiratory changes
• Meningeal Signs
– Photophobia
– Nuchal rigidity
Looking at Coma Assessment
• Levels of Consciousness; what is the difference between obtunded and stuporous??
• One is either aware of their surroundings or not
• Etiology
– Structural (BT, Aneurysm); ischemia, hemorrhage, compression
– Metabolic; hypoxia, hypoglycemia, electrolyte imbalance, acid/base changes, sedation and psychogenic
THE COMA ASSESSMENT
• Breathing pattern changes
• Changes in eyes; corneal reflex, pu;illary changes, dolls eyes
• Facial symmetry
• Swallowing vs. drooling
• Neck assessment
• Noxious stimuli
• Deep tendon reflexes,
• Babinski
• Posturing
86

NURSING INTERVENTIONS
• Patent Airway
• Assessments
• Avoid unnecessary stimuli
• Vital Signs
• Position – integumentary problems
• Elimination
• Protect eyes
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
87

N242
By the end of this learning experience, the student will be able to:
1.
Compare and contrast cluster and migraine headaches
2.
Describe the nursing care of a patient with migraine headaches.
3.
Identify common medications for migraine headaches.
4.
Differentiate between mild, moderate and severe head injury.
5.
Describe the potential complications following a head injury.
6.
Explain the necessary nursing assessment for a head injured patient.
7.
Implement a plan of care for the head-injured patient.
8.
Identify three types of brain tumors and the related pathophysiology.
9.
Discuss the typical clinical manifestations related to brain tumors.
10.
Differentiate between pheynotoin and dexamethasone.
Critical Thinking Activity
1. A patient who has been diagnosed with a brain tumor and will be having a craniotomy to remove the tumor. He is concerned because the neurosurgeon said he may be paralyzed after the surgery. He asks you if this is a fact. Your best response would be.....
88

Slide 1
HEAD ACHES
• Migranes
– Hereditary
– Vasoregulative instibility
– Females 3:1
– Symptoms?
– Treatments
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 2
MIGRAINE TREATMENTS
Prophylactic treatment May be needed if
Attacks are severe enough to impair quality of life or 3 or more severe attacks per month that fail to respond adequately to abortive or symptomatic therapy. All effective prophylactic agents decrease the frequency of migraine by 40%, compared with placebo. Few controlled clinical trials demonstrate differences between two groups of drugs. Beta Blockers , Calciumchannel blockers Tricyclic analgesics,
Anti-epileptics, NSAIDS.
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 3
Lastly, about Medication for
Migraine Headaches
Mild attacks ; NSAIDS
Moderate Attack ; NSAID , Triptans,
DHE, Ergotomine
Severe Attacks ; Butorphanol
(Stadol), Chlorpromazine, Ketorolac, narcotic analgesics and any of the above meds
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
89

Slide 4
More about that head ache..
• Cluster
– Several times a day or week, then a rest period
– Seasonal, more males than females, precipitating factors
– Most pain felt over eye or near the eye
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 5
More on headaches …
• Tension
– Usually bilateral, frontal or occipital
– Muscular contraction; anxiety tension
• Sinus
– Seasonal
– Pain and pressure around the eyes, across the cheeks and the forehead
> Achy feeling in the upper teeth
> Fever and chills
> Facial swelling
> Nasal stuffiness
> Yellow or green discharge
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
90

INCIDENCE & ETIOLOGY
• Each year, at least 1.5 million Americans sustain a traumatic brain injury
• claims more than 50,000 lives and leaves more than
80,000 individuals with lifelong disabilities each year
• brain injury occurs when an outside force impacts the head hard enough to cause the brain to move within the skull or if the force causes the skull to break and directly hurts the brain
• injury can occur from motor vehicle crashes, firearms, falls, sports, and physical violence, such as hitting or striking with an object
• 30-50% mortality if admitted unconscious
• 90% of all fatal head injuries are accompanied by ↑ICP
PATHOPHYSIOLOGY
MECHANISMS OF INJURY
• Acceleration/Deceleration
• Primary Injury
• Secondary Injury
• Penetrating Injury
• Hyperextension/Hyperflexion, Rotation
• Shearing
Skull Fracture
• Linear
• Comminuted
• Depressed
• Compound
• Basilar
Concussion
• Signs / symptoms
• Assessments
• Patient Teaching
Clinical Manifestations of Head
Injury
• Hematoma
– Subdural:
• Collection of blood between dura and underlying brain tissue
• Mortality increases with Glascow at 6 or below
• Acute = up to 48 hours
• Sub-Acute = 2-10 days
• Chronic = More than 10 days. Popular with elderly. May be confused with senility
Clinical Manifestations continued
– Epidural
• Bleeding between the skull and the dura
• Results from low speed, blunt injury
• Arterial bleeding is a problem
• Common with temporal/linear fractures
• Classic sign – loss of consciousness → lucid period → rapid ↓ in LOC → needs emergency surgery (ICP monitor and possible burr hole)
91

Can it get any worse???
• Hemorrhage ………..
– ICH
– SAH (more to come later)
NURSING PROCESS
• ASSESSMENTS
– Changes in LOC
– Pupils - changes
• PROBLEM IDENTIFICATION
– Airway first, then consider the cerebral system
• GOAL: To prevent ↑ ICP
• INTERVENTIONS: Depends upon your problem
– consider the interventions for all patients with potential changes in LOC – ASSESSMENTS!!
REHABILITATION
LONG TERM CARE
• Chronic Subdural Hematoma
– Behaviors often mimic senility/dementia; that is a big reason for the diagnosis of chronic
• Long term effects:
– Behavior changes – coping patient/family
– Cognitive changes – unforgiving brain
92

N242
By the end of this learning experience, the student will be able to:
1.
Describe three interventions in the treatment of intracranial disorders.
2.
Explain the patient teaching and post-op care of a patient undergoing a craniotomy.
3.
Describe the common medication given to a patient who is post craniotomy; actions, dosages and side effects.
4.
Identify key nursing interventions for patient having had an interventional neuroradiologic procedure.
5.
Discuss typical complication following an intracranial procedure.
93

CRANIOTOMY
• INDICATIONS
– Removal of brain/cranial lesions
• PRE-OP TEACHING
– The usual
– Hair loss
– Post-op deficits
– Anticipated medications
– 72 hours post-op
POST-OPERATIVE CARE
FOR THE CRANIOTOMY
PATIENT
• COMPLICATIONS
–  ICP - edema
– Bleeding – hematoma
– Hypovolemic shock –we keep them dry!
– Hydrocephalus – related to a number of issues
– Respiratory problems
– Wound infection
– Meningitis
– Fluid and electrolyte imbalances
• NURSING PROCESS
– The usual set of vitals along with a neuro assessment; Glascow and specifics (depending on surgical procedure)
– Primary Nursing Diagnosis:
• High risk for altered tissue perfusion
(cerebral)
• Decreased Intracranial Adaptive
Capacity
THE GOOD, THE BAD AND THE UGLY
A summary of the craniotomy experience
• GOOD:
– Pre-op symptoms are gone
– Fewer bad hair days
– Can “one-up” anyone on body scars
– Looks like you may have been mugged, but you kept your wallet
THE GOOD, THE BAD AND THE UGLY
A summary of the craniotomy experience
• BAD
– CSF leak
– ↑ICP (compensatory failure)
– Seizures
– Permanent damage
– Long recovery
– Bleeding – hematoma
– Infection
– pain
THE GOOD, THE BAD AND THE UGLY
A summary of the craniotomy experience
• UGLY
– Herniation
– Coma
– Subarachnoid Hemorrhage
94

TRANSPHENOIDAL
• INDICATIONS:
– “For those hard to reach places” like the pituitary gland
• PATIENT TEACHING:
– Need to explain the approach
– Appearance afterwards
– Measuring the I/O
– Now why are we going to check on the patient ’s peripheral vision????
TRANSPHENOIDAL
• POST-OP CARE:
– Complications are much like those of the craniotomy patient
– Diabetes Insipidus
– Bleeding, edema and possible CSF leak
– Complaints of “suffocation” and “I can’t breathe ”
• NURSING CARE:
– Same as for a craniotomy, ASSESS and compare base line!
– Provide reassurance to the patient, as their appearance can be quite disturbing to them.
– Teach I/O measurement
INTERVENTIONAL
NEURORADIOLOGY
• For those really hard to reach places and difficult areas to fix! Those cranial vessels
• Patient teaching; refer to example in your syllabus p. 53
• Prepare for the same complications you might expect with any angiogram
• Specific interventions will be determined on a case by case method. If Total Artery Occlusion is performed, then bolus fluids! It is essential for collateral vessel expansion
STEREOTACTIC PROCEDURES
• CIRCUMSTANCES
– Those impossible to reach places within the cranial vault (Gamma Knife) or for precision in getting to an area for biopsy
• PATIENT TEACHING
– Usually short stay, needing to observe for 24 hours
– If a gamma knife is used, results may be evident some time after, perhaps
2years
• NURSING CARE, WHAT
COMPLICATIONS
– Biopsy; can be as detrimental as a craniotomy! Not as common, but does exist.
– Same assessments as the craniotomy patient except for the burr holes ….watch those and teach for s/s infection!!
PHARMOCOLOGY ..THE 2 D ’s
• DECADRON (dexamethasone): Best for cerebral edema
– Initial dose (pre-op or intra-op) =10mg
– Maintenance dose= 4-6 mg q 6 hours
– Taper this medication! Requires detailed patient teach
– Side effects over long term use, “moon face ”, “buffalo hump” Cushings like
DILANTIN (phenytoin sodium) AKA DPH
• Drug of choice to prevent seizure activity.
– Loading dose = 1000mg (IV or PO)
– Maintenance = 300-500 mg q day (may be divided)
– If IV only mix it with NS!!
– Many side effects with long term use (gingivitis)
– Dilantin rash
– Absorption issues; binds to calcium
– Encourage strict adherence to the regime as many patient feel if no seizures, why take this??
– Must be discontinued with a taper, but not as complicated as Decadron
– Routine labs to assess levels
• 10-20 ug/ml
95

N242
NURSING CARE OF THE PATIENT WITH CEREBROVASCULAR DISORDERS
Objectives
By the end of this learning experience, the student will be able to:
1.
Discuss the incident and social impact of cerebral vascular disorders, specifically Cerebral-
Vascular Accidents (CVAs).
Identify the major risk factors for developing CVAs. 2.
3.
4.
Compare and contrast the etiology of embolic and hemorrhagic CVA.
Differentiate the pathophysiology and clinical manifestations of embolic vs. hemorrhagic
CVA.
5.
6.
7.
Discuss the protocol for Brain Attack.
Identify, in sequence, the NIH stroke scale components
Relate the concepts of r-tPA; Mechanism of Action, method of administration and potential problems associated with this drug.
8.
9.
10.
11.
12.
Define subarachnoid hemorrhage and the common etiologies.
Equate the phenomenon of cerebral vasospasm with subarachnoid hemorrhage.
List the medical/surgical interventions for hemorrhagic CVAs.
Explain the vital nursing interventions for a patient on SAH precautions.
Identify long-term needs in the rehabilitation of the CVA patient
Critical Thinking Activity
Mrs. Hind, an 80 year old widow, has been admitted to the hospital with a diagnosis of R/O CVA. She lives in a home with her 88 year old sister. The two women meet their own needs with only minimal assistance from their children.
1.
2.
What are the key elements you, the nurse, would look for during the admission history?
What would you anticipate to be the discharge needs of this patient?
Identify the following medications/therapy for SAH…what role do they play in treating the patient with
SAH?

Dilantin

Decadron

Manitol

Nimodipine
 Triple “H”
96

Some facts about CVA …..
• Also known as (AKA) Stroke or Brain
Attack
• Most current name is Brain Attack
• About 700,000 Americans each year suffer a new or recurrent CVA. That means, on average, a stroke occurs every 45 seconds
• CVA kills nearly 157,000 people a year.
That's about 1 of every 15 deaths. It's the
No. 3 cause of death behind diseases of the heart and cancer.
• About every 3 minutes someone dies of a
CVA.
DEFINITIONS
… from your text
• CVA – A disruption in the normal blood supply to the brain.
• Types of CVAs
– Ischemic
– Embolic
– Hemorrhagic
• TIA – Transient Ischemic Attack
CLINICAL MANIFESTATIONS
• Clinical Manifestations are dependent on where the stroke occurs in the brain and the type
• Generally speaking … advice from www.strokefoundaation.org
– Sudden numbness or weakness of the face, arm or leg especially on one side of the body
– Sudden confusion, trouble speaking or understanding
– Sudden trouble seeing in one or both eyes
– Sudden trouble walking, dizziness, loss of balance or coordination
– Sudden, severe headache with no known cause
IMPORTANT TREATMENTS FOR
EMBOLIC/THROMBOLYTIC STROKE
–Brain
Attack
• rt-PA – Recombinant tissue plasminogen activator
– Genetically engineered drug; obtained from melanoma cells
– Very fast acting/ ½ life of 5 minutes
– Breaks down thrombus/embolism in the vessel
– Improvement of patient outcomes; studies have shown 30% better outcomes in patients receiving rt-PA
A FEW WORDS ABOUT
REHAB
…THE CHANGES ONE MUST
ENDURE
Although this content is delivered here, the changes are similar to those with any insult to the brain
•
COGNITIVE : L side = language
– aphasia; R side = visual, spacial awareness/proprioception. More mood changes Pt will take many months to recover full or
“best” cognition.
• MOTOR : Hemiparesis/paralysis. Teach pt awareness of effected side and safety precautions.
• SENSORY : May experience Neglect Syndrome
(unaware of the effected body side). If near the Optic chiasm, patient will experience visual deficits (acuity, visual fields etc..)
•
CRANIAL NERVES : Depends upon injury area; see many patients with swallowing problems - dysphagia
97

Subarachnoid Hemorrhage an overview
• AKA SAH
• Defined as a sudden bleeding into the ventricular system and/or subarachnoid space
• 10% of those who have a SAH will die immediately
• 60% of those who have a SAH will die within 30 days
• Occurrence increases after 50 ov erview
…continued
• Etiology: Non traumatic
– Aneurysm (80%)
– AVM (20%)
• Hunt and Hess grading system (classic
– Grade 1 - Asymptomatic or mild headache
– Grade 2 - Moderate-to-severe headache, nuchal rigidity, and no neurological deficit other than possible cranial nerve palsy
– Grade 3 - Mild alteration in mental status (confusion, lethargy), mild focal neurological deficit
– Grade 4 - Stupor and/or hemiparesis
– Grade 5 - Comatose and/or decerebrate rigidity
ANNEURYSM
• 80% found on anterior vessels of cerebral arterial system
• Variety of shapes
• Women more susceptible than men – 3:2
• Same risk factors as embolic/thrombolytic
• Bifurcation issue
Aneurysm Pathophysiology
• These are small, thin-walled blisters protruding from arteries: Usually occurs at a bifurcation, that is naturally thin-walled.
• Approximately 85% of all intracranial aneurysms arise within the Circle of Willis. Common locations are the anterior communicating artery
(30-35%), the internal carotid artery (ICA) at the posterior communicating artery origin (30-35%), and the MCA bifurcation (20%)
•
No one really knows the precise cause, perhaps congenital? Some people are more susceptible? HTN and smoking contribute to their ruptures.
And the
…. AVM
• A rterio v enous M alfomation
– Entangled mass (nidus) of abnormal vessels without an intervening capillary bed, demonstrating rapid arteriovenous shunting.
– Wedge shaped → compression
– “robs” normal blood flow → ischemia
–  venous pressure = hemorrhage
– Clinical manifestations based upon injury extent and location
Diagnostics
• For all Brain Attack conditions…a CT scan is performed immediately to determine if the attack is embolic or hemorrhagic
• An MRI maybe performed to define location and age of the brain attack
• Cerebral Angiogram; if warranted and only for the hemorrhagic type
98

Clinical Manifestations.. Specific for
SAH
• Look these up!
– Meningeal Signs
– Cerebral signs
– Spinal signs
– Hydrocephalus
– ↑ICP
– Hypothalmic Signs
Medical/Surgical Interventions for
Aneurysm
• Medical
– control ↑ ICP
– Prevent seizures
• Craniotomy
– Clip, wrap or bypass
• Interventional Neuroradiology
– Coils
– Total Artery Occlusion
Medical/Surgical Interventions for AVM
• Medical
– control ↑ ICP
– Prevent seizures
• Surgical/Invasive
• Interventional Neuroradiology
– “kill” the feeder vessels
• Craniotomy
– Clip and cut out
• Gamma Knife
Nursing Interventions for Hemorrhagic
CVA
• Aneurysm/SAH precautions
– Quiet room
– Keep lights down
– Maintain ABCs
– ↓ICP → keep head elevated
– Maintain pain control
– Astute neurological assessments
– Stool softener
– Prevent vasospasm
Nursing Interventions for Hemorrhagic
CVA
• Administer prescribed medications/therapeutic regimens (look these up before class)
– Dilantin
– Decadron
– Manitol
– Nimodipine
– Triple “H”
Evaluation of patient outcomes
• Remember, the brain will take a long time to heal
• There are potentially life long deficits with
CVAs that the patient must adapt to
• CVA or Brain Attack is being addressed more in the public arena …with quick intervention, perhaps we will see a decline in the very expensive and extensive problems with rehabilitation
99

N242
1.
OBJECTIVES: By the end of this learning experience, the student will be able to:
1.
Define seizure and epilepsy.
2.
Explain the pathophysiology, etiology and clinical manifestations of epilepsy.
3.
Differentiate between partial and generalized seizures.
4.
Explain the nursing assessment during a seizure.
5.
Discuss important nursing documentation regarding seizures.
6.
Identify common anti-convulsive medications.
7.
Discuss the variety of non-pharmaceutical interventions for convulsive disorders.
Critical Thinking Activity
Define the International Classifications for convulsive disorders.
3.
Slide 1
You admit a patient who has just experienced her first seizure. The MD orders seizure precautions. How can you implement that order?
___________________________________
___________________________________
The last decade has seen significant advances in the surgical treatment of epilepsy. The area of the brain with abnormally discharging neurons (the seizure focus) is surgically removed, if it is possible to identify this area and remove it safely. Or, in certain patients without a well-defined epilepsy focus, surgically disconnecting or isolating the abnormal area so that seizures no longer spread to the neighboring normal brain can help.
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
100

Slide 2
DEFINITIONS
• Seizure : Sudden disorderly discharge of cortical neurons in the brain with distinct changes in behavior and body function.
• Epilepsy : Recurrent Seizures
• Look these up your selves:
– Prodrome
– Aura
– Ictus, inter ictal, post ictal
– Convulsions
– Automatism
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 3
ETIOLOGY
• Genes/chromosomes
– Genetic predisposition
• Structural
– Brain tumor, aneurysm
• Metabolic/Nutrient
– Electrolyte imbalance, diabetes -
• Noxious stimuli, stress
• Idiopathic (unknown cause)
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 4
PATHOPHYSIOLOGY
Epileptogenic focus (look it up!) → Local neurons fire excessively
→
Recruit adjacent neurons to fire
→
May recruit distant neurons
Sufficient neurons fire Abnormal electrical discharge
Clinical Manifestations No Changes
Clinical Manifestations depend upon the part of the brain from which the discharge began and the path in which it spreads
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
101

Slide 5
INTERNATIONAL CLASSIFICATION
• Partial (involves part of the brain)
– Simple partial
– Complex partial
– Partial, secondary to generalized
• Generalized (involves entire brain)
– Absence
– Tonic-clonic (May be tonic or clonic or both)
– Akentetic
– Infantile
– Myoclonic
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 6
CLASSIFICATION
Old classification (still used today) vs. new
Example
Petit Mal = Partial Seizures
Grand Mal = Generalized Seizure
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 7
STATUS EPILEPTICUS
• Recurrent seizure activity lasting 30 minutes or longer
• Patient with known seizures are at risk
– Types
• Tonic clonic status
• partial complex (Petit mal) *
• Focal
• electrical
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102

Slide 8
NURSING PROCESS
• Monitoring a seizure
– Date, time of onset, duration of seizure
– Activity of patient during onset
– Precipitating factors
– Aura
– Seizure activity
– Autonomic signs
– LOC, during and after
– Postictal state
– Presence of injury
___________________________________
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Slide 9
NURSING PROCESS
• Management during….
– Protect from injury
– Maintain airway
– Do not force objects into mouth!!
– Do not restrain
• Pharmacology
– Anticonvulsants
– Sedation
• Management; pre-op, intra-op, post-op
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Slide 10 ___________________________________
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103

Slide 11
Partial and Generalized
• Phenytoin (Dilantin)
• Carbamazepine (Tegretol)
• Phenobarbital
• Primidone (Mysoline)
• Divalproex sodium (Depakote)
• Topriamate (Topamax)
• Gabapentin (Neurontin)
___________________________________
___________________________________
___________________________________
___________________________________
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Slide 12
Absence and Other Generalized (non clonic) seizures
• Ethosuximide (Zarontin)
• Divalproex sodium (Depakote)
• Clonazepam (Klonopin)
___________________________________
___________________________________
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Slide 13
Status
• Diazepam (Valium)
• Lorazepam (Ativan)
• Phenytoin (Dilantin)
• Phenobarbital
• Paraldehyde
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104

Slide 14
Surgery
• Who is eligible?
– Persons with medically intractable epilepsy
• How is the epileptogenic focus found?
– MRI, PET and SPECT can play an important role in the localization of abnormal cortex and
Video/EEG monitoring
• What if the area detected is not specific?
– Electrodes are placed over the area and the patient is monitored
• Epidural, subdural, intracerebral (the deeper they go, the more at risk for infection)
___________________________________
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Slide 15
Surgery
….
• Once the area of the brain is located the patient will undergo
– Resection
• lesionectomy, lobectomy, hemispherectomy,
– Disconnection
• callosotomy
– Augmentation
• cerebellar and vagal stimulation
– Stereotactic Ablasions
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Slide 16
-The Epileptogenic is found with the external electrodes
-The hair is being removed in preparation for surgery
-Internal electrodes help to further define the are
- Brain tissue is removed
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105

Objectives :
1.
2.
3.
4.
5.
By the end of this learning experience, the student will be able to:
State the areas of the spinal cord that are most prone to injury and why.
Identify the etiology and epidemiology of Spinal Cord Injury.
Describe four major mechanisms of spinal cord injury.
Define the classifications of spinal cord injury and the associated manifestations.
Discuss the syndrome of spinal shock and the medical and nursing interventions associated.
Identify five nursing diagnoses associated with spinal cord injury. 6.
7.
8.
9.
Describe the nursing actions related to Autonomic Dysreflexia.
List the goals of rehabilitation for the patient with paraplegia and tetraplegia.
Develop a plan of care for the patient with intervertebral disc disease.
1.
Where are the following anatomical features located on the spinal cord and what function do they perform?
Critical Thinking Activity

Anterior median fissure

White Matter

Ventral Root

Gray Matter

Dorsal Root Ganglia

Dorsal Root

Posterior Median Sulcus

Central Canal

Posterior Gray Horn

Gray Commissure

Anterior Gray Horn

Spinal Nerve
2. At your clinical agency you may have taken care of a patient with a spinal cord injury. What was the bowel regimen for that patient. (If you have not, describe a typical bowel regimen).
3. Martin, a 30 year old nursing student, has been admitted to the hospital with a herniated disc of L4 to L5. He had a very active youth, playing school sports and teaching scuba diving during the summers. After high school he enlisted in the Marines and was involved in several outdoor training maneuvers as well as practicing weight lifting. In his last eight weeks of nursing school,
Martin was vacuuming his apartment. As he bent over to move a plant, he was struck with a sudden sharp low back pain. At the ER he described the pain as beginning in his lower back and running down his buttocks to his left thigh. a. What additional information should you obtain?
4. After one day of observation in the hospital and one week of bed rest, the physician allows Martin to return to school and “light duty”.
106

a. school?
What nursing interventions (non-pharmacological) could help Martin as he returns to
FACTORS INFLUENCING SPINAL
CORD INJURY
• Close anatomical relationship of vertebrae, soft tissue, cord and disc → ↑s probability that any one of these structures can cause concurrent injury to any one or all of the other structures
• Kinetics: Cervical spine has a possible 80° flexion and 75 ° extension = extreme vulnerability to injury
EPIDEMIOLOGY: SPINAL CORD
INJURY
US Statistics
– Spinal Cord Injury information Network
• Incidence: 11,000 new cases each year
• Prevalence: 225,00-288,000 persons alive with injury
• Age of injury: 37.6
• Gender: 79.6% Young Males
• Ethnic Groups: 62.9% are Caucasian, 22% African
American, 12.6% Hispanic, and 2.5% all other groups
• Occupational Status: 61.4 % employed at time of injury
• Cost: Hundreds of thousands – multimillion
• Cause of death after injury – pneumonia, pulmonary emboli and septicemia
MECHANISMS OF INJURY
MATCH THE FOLLOWING
•ACCELERATION
•DECELERATION
•DEFORMATION
•AXIAL LODING/VERTICAL
COMPRESSION
•PENETRATING
•SCIWRA
•EXESSIVE ROTATION
1.
A bullet wound near the spinal cord
2.
Diving into a pool
(shallow) or falling from a ladder
3.
MVA
4.
Arnold Chiari
Malformation
5.
Hanging
6.
Stabbing or GSW: maybe Brown Sequard
INITIAL CORD RESPONSE
• Incomplete injury vs. Complete injury
– Partial loss of function below level of injury vs.
Total loss of function below level of injury
• Clinical manifestations
– Depends upon level of injury
107

The Syndromes
• ANTERIOR – paralysis below the injury with variable impairment of pain and temperature sensation is present. Position and vibration modalities are preserved
• CENTRAL – most common in the elderly. Hyperextension.
Loss of upper extremities over lower
• POSTERIOR – very rare, proprioception and deep pressure loss, while motor is preserved
• CUADA EQUINA –
S1 or below. Good prognosis
• SOFT TISSUE –
AKA
– whip lash
• BROWN SEQUARD –
Ipsilateral motor/proprioception loss with contralateral pain and temperature loss.
NURSING PROCESS: Prehospitalization
• Rapid assessment to determine level of injury
• Immobilization
• Move patient to safety
• Stabilize vital signs
• transport
NURSING PROCESS: ER
• Respiratory (anything above T1) maintain vital signs
• History – What happened?
• Assessments – Neurological exam
• Insert Foley catheter (may happen later)
• Diagnostics – X ray → CT → MRI
• Begin steroids – within 3 hours after injury:
– 30 mg/kg IV bolus over 15 minutes, followed by 5.4 mg/kg/h over
23 hours, Begin IV infusion 45 minutes after conclusion of bolus
** must determine if the risks of side effects outweigh the benefits of the med
• Determine process of stabilization: Brace (neck, halo vest), traction, Surgery
NURSING PROCESS: Beyond ER
• Expect Neurogenic Shock: Temporary (a few days – few months)
– Orthostatic hypotension
– Bradycardia
– Flaccid paralysis
– Possible paralytic ileus
– Decreased urine output
• Followed by Autonomic Dysreflexia
NURSING PROCESS: ICU/SCI Unit
• Assessment of Injury continues
– Motor
– Sensory
– CV
– Respiratory
– GI
– Ms
– Psycho/social – long lasting issues, taxes coping skills
NURSING PROCESS: Recognize the Emergencies
• Respiratory dysfunction
• Cardiovascular dysfunction
• AUTONOMIC DYSREFLEXIA
– Can be experienced well after the initial injury
– Characterized by ↑ V.X., pounding head ache, nasal congestion…
– What does the nurse do ?
108

NURSING PROCESS: Rehab
• Spasticity
– After neurogenic shock has resolved
• Bladder Dysfunction
– Teach intermittent catheterization
• Sexual Dysfunction
– Penile implants
• Psychosocial Issues
– Loss
– adaptation
NURSING PROCESS: Rehab continued …….
• GOALS (ordered from first to last)
– Stabilize
– Participation with T, OT etc…
– ADL’s
– Successful adjustment to home (80% return to pre-injury resident)
– Integration into the community
– Gainful employment
– Independence
NURSING DIAGNOSIS
• You tell ME…Priorities in the following areas
– ER
– ICU/SCI Unit
– Rehabilitation
– Home
– ER
• Ineffective breathing pattern
• Ventilation, spontaneous; inability to sustain
• Gas exchange, impairment
• Cardiac output, decreases
– ICU/SCI Unit
• Mobility impairment
• Sensory, alteration
• Airway clearance, ineffective
• Incontinence
• Dysreflexia
• Fear
• Grieving, dysfunctional
– Rehabilitation
• Dysreflexia
• Constipation
• Skin integrity impaired
• Grieving, dysfunctional
• Hoplessness
• Body image disturbance
• powerlessness
– Home
• dysreflexia
• Health maintenance, alteration
• Social isolation
• Sexual dysfunction
BACK PAIN
• Most common- herniated disc
• The facts
– 30-60 year olds
– = sexes
– ↓ disc fluid + fibrous ligaments = herniation
– Smoking → ↓ 0 ² in disc → prone to herniate
109

BACK PAIN
• Pathophysiology
– With aging disc, add a sneeze, awkward movement or MVA and you can cause a protrusion or herniation
– May spontaneously reabsorb
– Usually causes chronic spinal nerve root irritation
→ chronic pain
BACK PAIN
• Clinical manifestations = level of injury
• Diagnostics; better with the MRI
• Medical Management
– Nothing, PT, Acupuncture/pressure, chiropractor, positioning
– Drug therapy – muscle relaxant + antiinflammatory
– Surgery
Discectomy vs. laminectomy
Discectomy: removal of a ortion of the disc
Laminectomy: removal of the one or more vertebral laminae, bone spurs (if present) and herniated nucleus (if needed)
BACK PAIN
• Nursing Process
– Assessment: level of spinal cord, symptoms
(pain, numbness, mobility)
– Pre-op teaching : Cervical vs. Lumbar
(discecktomy vs. laminectomy)
– Surgical Intervention: Cervical Spine vs.
Lumbar spine
• Does the patient need a fusion??
110

N242
NURSING CARE OF THE PATIENT WITH INFECTIOUS, INFLAMMATORY OR
AUTOIMMUNE DISORDERS
OBJECTIVES : By the end of this learning experience, the student will be able to:
1.
Compare and contrast the disease processes of Meningitis, Brain Abscess, Encephalitis.
2.
Discuss the infective agents and the related medical treatments concerning the patient with AIDS
Dementia Complex.
3.
Identify the priority problems facing the patient with AIDS Dementia Complex.
4.
Describe the collaborative treatment for the patient with infectious and or inflammatory CNS disorders.
5.
Identify the common complications of infectious disorders of the nervous system and the related nursing interventions.
6.
Apply principles of nursing management to the care of the patient with infections, inflammatory and autoimmune disorders of the nervous system.
7.
Compare and contrast the disease processes of Multiple Sclerosis and Guillain-Barre Syndrome
8.
Evaluate the needs of the patient’s family for information emotional support, and planning concerning infectious, inflammatory and autoimmune disorders of the CNS.
9.
Evaluate the home care needs of patients with chronic nervous system disease processes.
Critical Thinking Activity
1. Compare and contrast Multiple Sclerosis and Guillain-Barre Syndrome. etiology manifestations diagnostics interventions prognosis
MS GBS
111

MENINGITIS
• Definition:
An inflammation of the meninges of the CNS
• Etiology
– Bacterial worse than viral
–
Fungal less common, persons with impaired immune systems, chronic
MENINGITIS
• Pathophysiology
– Enters CNS through penetrating trauma, surgical procedures, sometimes unclear  enters vasculature

 increasing permeability mobilization to the meninges
 purulent exudate develop in the Pia and Arachnoid mater
 coats structures and
“clogs” arachnoid villi
– Fungal type forms masses and granulomas
MENINGITIS
• Clinical Manifestations
– Headache
– LOC changes
– seizure
– Nuchal rigidity
– Meningeal irritation
– Kernig’s sign
– Brudzinski’s sign
• Diagnosis
– CSF analysis
• Treatment
– Proper ABX
BRAIN ABCESS
• Defined:
– Encapsulated lesion
• Etiology
– infections within the middle ear or mastoid
(teeth), sinus
• Pathophysiology
– Begins as a diffuse lesion  encapsulates
 may spread with more lesions
BRAIN ABCESS
Clinical manifestations
– Flu like symptoms, focal or gen. Sz., motor, sensory or speech problems (depends upon lesion location)
• Medical interventions
– Bx. abcess  determine organism  may surgically remove and/or treatment with ABX, direct/indirect
HERPES SIMPLEX
ENCEPHALITIS
• Epidemiology
– All ages
– 70% mortality if not treated in a timely fashion
– Non-epidemic, but life threatening
• Etiology
– HSV
I or II
– Originates as a cold sore
112

HERPES SIMPLEX
ENCEPHALITIS
• Pathophysiology
–
HSV produces cytolytic infection
→ inflammation
→ 
ICP, especially in temporal lobes
→ destroys and necrosizes neurons
→ cerebral edema and hemorrhage
→ 
ICP, especially in temporal lobes
HERPES SIMPLEX
ENCEPHALITIS
• Diagnostics
– CSF, Hematology, EEG, CT, Brain Biopsy
• Clinical manifestations
– Generalized symptoms appear several weeks after primary infection
– Common neurological symptoms
– Diffuse CNS involvement
– Neuralgic sequelae (nerve roots irritationitching, burning)
HERPES SIMPLEX
ENCEPHALITIS
• Treatment
– HSV = IV Acyclovir
– Treat the ↑ICP
AIDS AND THE CNS
• Definition
– AIDS Dementia Complex (subacute encephalitis, encephalopathy)
– Better medical management =  incidences with AIDS dementia complex
– Although 40 – 50% of those who have AIDS will end up with neurological impairment Etiology
– Varied opportunistic viral and non-viral infections
AIDS AND THE CNS
• Diagnosis
– the usual “neuro tools”
• Clinical manifestations
– cognitive impairments, memory and attention deficits, apathy and withdrawal, becomes aware of cognitive impairments
• Medical interventions
– Meds aligned with type of infectious agent
– Radiation
– Supportive therapy
Nursing Process
• Assessment
– Neurological assessment; the usual
– Noting any changes in the baseline assessment
• Nursing Diagnosis
– Decreased Adaptive Capacity – Intracranial
– Ineffective Tissue Perfusion – Cerebral
– Any specific N. Diagnoses that address the symptoms
113

Nursing Process
• Outcomes
– Management of ↑ ICP
– Maintain a balance between ICP and CPP
– Any related outcomes to the specific N. Dx.
• Interventions
– The usual that come with ↑ ICP
MULTIPLE SCLEROSIS
• Defined
• Epidemiological facts
• Etiology
• Pathophysiology
• Characteristics
– Various symptoms
MULTIPLE SCLEROSIS
• Definition:
Brunner (1992) “A chronic, degenerative disease of the CNS characterized by the occurrence of small patches of demyelination in the brain and spinal cord
• Epidemiology
– First symptoms usually appear in the early 20’s
– Females > males
– Higher socioeconomic, urban areas
– Familial disposition
– Degrees of illness
MULTIPLE SCLEROSIS
• Etiology
– Specific causes unknown
– Possible mechanisms
• Susceptibility gene
• Infection by slow virus
• Autoimmunity
• Cell-mediated immune reaction
MULTIPLE SCLEROSIS
• Pathophysiology
– Demyelination of the CNS
• Process is randomly distributed
• Inflammatory process
• Plaques form and found anywhere in CNS
• Exacerbates and remises
MULTIPLE SCLEROSIS
• Clinical Manifestations
– Chronic, unpredictable, progressive
– Generalized fatigue
– Heat intolerance
– Factors influencing exacerbation
• Pregnancy
• Infection
• Allergies
• surgery
114

MULTIPLE SCLEROSIS
• Diagnostics
– History
– CSF analysis
– Evoked potentials – stimuli/EEG
– CT and MRI
• Physical Assessment May Reveal
– Cerebral=sensory symptoms, motor symptoms
– Cranial=optic neuritis, nystagmus, diplopia
– Cerebellar=ataxia, intentional tremors
– Spinal=  genital sensation
– Sensory= “electric shocks”
– Generalized=sz. Activity
– Psychiatric=depression, anxiety
MULTIPLE SCLEROSIS
• Different methods of treatment – nothing definitive
• Nursing Process
– Highlight problems (sensory, nutrition, Immobility,
Communication, elimination, role functioning, injury
– develop appropriate plan of care
• Ongoing
– Debilitating disease → Multiple N. Dx.
– Adaptation in home and environment
– MS society
GUILLAIN-BARRE
• Defined:
– A nervous system syndrome with unknown causes involving both cranial and peripheral nerves
• Epidemiology
– Effects 1.7/100,000 people
• Etiology
– History of recent acute infection, trauma or emotional upset
– Basically, unkown
GUILLAIN-BARRE
• Pathophysiology
– Diffuse inflammatory reaction – peripheral nerves
– Lymphocytic infiltration
– Breakdown of myelin – segmental
– Axon atrophy
– Pathological process ceases
– Remyelination occurs slowly
– Total process from onset to complete recovery + 6=24 months
GUILLAIN-BARRE
• Cardinal features/types
– Abrupt and progressive onset of symptoms
– Symptoms present bilaterally, symmetrically in both ascending and descending patterns
• Ascending most common; starts with weakness/numbness in feet → legs etc…
• Descending → cranial nerves
→ reflexes
→ rapid respiratory decline
– 30% will describe pain in muscles and/or sensitivity to pressure
– No muscle atrophy due to sudden onset of paralysis
GUILLAIN-BARRE
• Clinical course
– Initial progressive phase; 1-2 weeks
– Plateau phase; days – weeks
– Recovery phase; as remyelination occurs, can take up to 2 years
• Medical interventions
– Steroids
– Plasmopharesis
– Supportive care
115

GUILLAIN-BARRE
• NURSING CONCERNS
– Pt. Is conscious; frightened
• Needs a lot of support/reassurance
– Maintain respiratory integrity
– Communication
– Skeletal Muscle
– Integumentary
116

N242
OBJECTIVES: By the end of this learning experience, the student will be able to:
1. Identify the physiological and psychosocial principles underlying the medical and nursing regimens for the patient with a degenerative neurological disorder.
2 Discuss the support needed to assist in establishing positive coping mechanisms
3. to be used by the patient and family.
List the patient and family education diet, exercise, medications, and
complications associated with the varied degenerative diseases.
4.
Explain the patient’s need for independence and safety when evaluating the varied degenerative disorder presented.
2.
1.
5. Implement the nursing process for a patient and family with a degenerative
disease.
6. Identify emergent problems associated with the varied degenerative neurological diseases presented.
Critical Thinking Activity
Mr. Roberts has been diagnosed with Myasthenia gravis and is in crisis. How can a plasma exchange be useful?
The following terms are associated with degenerative disorders. Briefly define these terms. agnosia apraxia ataxia dyskinesia fasciculations orthosis dystonia
117

ALZHEIMERS
• Definition: A progressive, chronic and degenerative disease of the brain, resulting in memory deficits, cognition deficits and inability to care for oneself.
Etiology
• Unknown
• Theories
– Neurotransmitter
•  acetylcholine
• Genetic factors (certain types of Alz.)
– Pre-programmed cell death
• Beta amyloid protein and plaques
 neurodegeneration
– Miscellaneous
– Virus?
– Arteriosclerosis?
– Head injury
– Slow virus???
•
•
Pathophysiology
• Symmetrical brain atrophy
Degenerative neuronal changes
Major areas of degeneration
• and
Decrease of choline acetyltransferase in cortex hippocampal areas
ALZHEIMER ’S STAGES
1. Forgetful (subtle, pt. May cover up),
 interest in social, poor work performance
2. Memory loss,  physical activity, speech problems, looses; way home, social graces, irritable
3.
 Wt., unable to communicate,, sz.,
 recognition of family
•
Death due to aspiration pneumonia
PHARMACOLOGY
Current Medications
Approved for treatment of Alzheimer’s are:
• Namenda
(memantine)
Blocks the toxic effects associated with excess glutamate and regulates glutamate activation. Nmethyl D-aspartate
(NMDA) antagonist prescribed to treat symptoms of moderate to severe AD
• Razadyne (formerly known as Reminyl)
(galantamine)
Prevents the breakdown of acetylcholine and stimulates nicotinic receptors to release more acetylcholine in the brain.
Cholinesterase inhibitor prescribed to treat symptoms of mild to moderate AD
MORE PHARMACOLOGY
• Exelon (rivastigmine)
Prevents the breakdown of acetylcholine and butyrylcholine (a brain chemical similar to acetylcholine) in the brain. Cholinesterase inhibitor prescribed to treat symptoms of mild to moderate AD
• Aricept (donepezil)
Prevents the breakdown of acetylcholine in the brain.
Cholinesterase inhibitor prescribed to treat symptoms of mild to moderate AD
• Cognex (tacrine)
Prevents the breakdown of acetylcholine in the brain.
Cognex is still available but no longer actively marketed by the manufacturer.
Cholinesterase inhibitor prescribed to treat symptoms of mild to moderate AD
118

MORE PHARMACOLOGY
• A variety of additional medications are used.
These are for problems associated with disease
• Choline derivatives
– choline, lecithin
• Vasodilators
– Papaverine (Pavabid)
– Ergoloid mesylates
(Hydergine)
– Cyclandelate
(Cyclospasmol)
• Cholinergic receptor stimulant
(a few more)
– Bethanecchol chloride
(Urecholine)
• Physotigmine
– Inhibits acetylcholinesterase
– Slows Ach breakdown
• Psychostimulants
– Methylphenidate hydrochloride
(Ritalin)
NURSING PROCESS
• ASSESSMENT
– Identify stage of disease
– Determine deficits
– Assess both patient functioning and impact on family
– What other assessments?
• NURSING DIAGNOSIS
– Diagnoses are many, you can list these
– Family concerns and problems become issues to deal with in the care plan
NURSING PROCESS .. Continued
• OUTCOMES
– Patient will remain safe
– Independence is promoted
– Family is supported
• INTERVENTIONS
– Specifically address the outcomes
– What are some helpful interventions concerning safety, memory stimulation, family support?
– What stage will you find more physically based nursing diagnoses and the related interventions?
NURSING PROCESS .. Still more
• Evaluation
– What are your primary outcomes?
– Did the patient meet these?
PARKINSON ’S
• A disease of the basal ganglia.
Brunner (1992), “Progressive neurological disorder affecting the brain centers that are responsible for control and regulation of movement.
”
PARKINSON ’S
• Etiology and precipitating factors
– Idiopathic Parkinsonism
• Etiology unknown in 85% of all individuals with
PD
• Possibilities: Genetic, viral, toxic, multifactorial causes, premature aging of dopamine neurons
– Secondary Parkinsonism
– Neurotoxins
– Post-encephalic
– Structural causes
– Drug-induced pseudoparkinsonism
– Atherosclerosis
– Viral encephalitis
– Metabolic causes
119

PARKINSON ’S
• Pathophysiology
– Extrapyramidal System: Degeneration and loss of pigmented cells
– Remaining cells contain eosinophilic cytoplasmic inclusions
– Neuronal loss
– Greater cell loss due to lower concentration of dopamine
– Decrease in amount of dopamine and HVA
•
STAGES
→
Unilateral
→
Bilateral
→
Impaired postural &
“righting” reflexes →
Fully developed with marked disability
CLINICAL MANIFESTATIONS
• Major motor signs
– Muscle rigidity
– Tremors
– Bradykinesia
– Postural instability
– Mask like face
THERAPEUTIC MANAGEMENT
• No known cure
• Pharmacology
–
Amantadine hydrochloride (Symmetrel)
• Increases endogenous dopamine available
–
Bromocriptine mesylate (Parlodel)
• Decreases dopamine turnover
–
Pergolide (Permax)
• Dopamine agonist
More on the next slide!
DOPAMINERGICS
• Levodopa
Carbidopa
Levodopa/Carbidopa (Sinemet)
• What do the Dopamine products do?
– Dopamine is converted and able to get to the brain
• Contraindications
– CAD, psychosis
• Side effects
– ORTHOSTATIC HYPOTENSION
• Pt. Teach
– Some foods to avoid
– Need to take with food
– Ted hose
– Depression
Still more medical treatments
•
Other meds include
– Monoamine oxidase-
B inhibitors
–
Anticholinergic agents ( Parsidol,
Cogentin)
– Antihistamines
(Benadryl - reduce tremors)
• Other treatments…
– Surgery
– Ablative lesion
– Thalamatomy
– Autologous transplantation of adrenal medullary tissue into brain
– Fetal transplant tissue
– Deep brain stimulation
120

NURSING PROCESS
• ASSESSMENT
– Clinical manifestations; determine stage
– Ability for self care?
• NURSING
DIAGNOSIS
– YOU NAME THESE!
• OUTCOMES
– Related to your N.
Diagnosis
• INTERVENTIONS
– Related to your outcomes
• Evaluation
– More likely to occur as an outpatient – therefore evaluation ongoing based on problems experienced
HUNTINGTON ’S DISEASE
• Definition: An inherited chronic, progressive, disease of the nervous system that results in involuntary choreiform movement and dementia.
(Brunner, 1992)
HUNTINGTON ’S DISEASE
• Etiology
– Inherited autosomal dominant gene
– located on chromosome 4
• Pathophysiology
Degeneration of small to medium size cells in corpus stratium
→
Disproportionate decrease of small versus microsized neurons
→
Curling, branching and arborization of dendrites
→
Neuronal cells are replaced with glial cells from fibrous astrocytes
Then
….. →
Moderate atrophy of gyri of frontal and temporal lobes →
Decreased glucose metabolism in affected areas
→
Neurotransmitters effected → Changes in receptors
→
Effects pathways
HUNTINGTON
’S DISEASE
Characteristics and Classification
(progression varies)
•
Early stage
– no functional deficits
•
Early intermediate
– lower level of function, still able to work
•
Late intermediate stage
– Not able to work, unable to manage household responsibilities
• Early advanced stage
– Not independent in ADL, supported home environment required
•
Advanced stage
– Professional care needed, no ADLs
HUNTINGTON ’S DISEASE
• Clinical
Manifestations
– Personality changes
– Affective and psychiatric disorders
– Depression
– Intellectual decline
– Movement disorders
– chorea
• Diagnostics
– DNA typed
– To define progression
– CT
– PET
•
HUNTINGTON ’S DISEASE
Therapeutic Management
– No known cure
– Pharmacology
• Dopamine receptor-site antagonists
•
Phenothiazines (Chlorpromazine)
•
Butyrophenone (Haloperidol - Haldol)
• Thiothixene (Novane)
•
Agents to deplete presynaptic dopamine
• Reserpine
• Alpha-methyl paratyrosine
•
Cholinergic agonists
• Physostigmine
121

N242
1.
Objectives:
1.
By the end of this learning experience, the student will be able to:
Differentiate between mononeuropathy and causalgia.
2.
3.
4.
5.
6.
Describe the common causes of peripheral neuropathies.
Describe the nursing management for patients with trauma of the peripheral nerves.
Compare the pathophysiology and clinical manifestations of trigeminal neuralgia and facial nerve paralysis.
Discuss the medical management for patients with both Trigeminal Neuralgia and Bell’s Palsy.
Identify the nursing problems associated with both Trigeminal Neuralgia and Bell’s Palsy.
Critical Thinking Activity
How would you assess the functioning of the: trigeminal nerve facial nerve
2.
Discuss the safety precautions one would implement and teach the person with a peripheral nerve disorder affecting the lower extremities.
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PERIPHERAL NERVE
DISORDER
Definition: A disorder affecting the peripheral motor, sensory or autonomic nerves (Brunner,
1992)
• Motor nerves are responsible for the voluntary movement of the body and its parts
• Sensory nerves allow us to feel pain, vibrations or touch, temperature and to sense where our limbs are positioned
• Autonomic nerves control involuntary functions like breathing, the pulse, blood pressure, digestion and sexual function
• Mononeuropathy: Causes are direct trauma, prolonged pressure on the nerve and compression of the nerve by swelling or injury to nearby body structures ulnar nerve compression
• Multiple Mononeuropathy: inflammatory occlusion of the blood vessels peripheral vascular disease
• Polyneuropathy: Begins bilaterally and distally at hands or feet diabetes
Pathophysiology
• Wallerian = severed axon
• Segmental = spots along the nerve axon are not functioning
• Peripheral nerves can and do regenerate, although not always the way we would like
…
• During regeneration more pain pathways are established, causing more intense and chronic pain
• Sometimes nerves regenerate and get
“mixed-up”; motor nerves may regenerate as more sensory
A Variety of Symptoms
• A sensation of wearing an invisible "glove" or
"sock.
“ sensory
• Burning sensation or freezing-like pains sensory
• Sharp, jabbing or electric-like pain sensory
• Extreme sensitivity to touch sensory
• Difficulty sleeping because of feet and leg pain sensory
• Loss of balance and coordination sensory
• Muscle weakness motor
• Difficulty walking or moving the arms motor
• Abnormalities in blood pressure and pulse autonomic
What are these??
• Paresis
• Paralysis
• Atrophy
• Dysthesias
• Autonomic problemsa
SOME OF THE SPECIFIC
PROBLEMS
• TRAUMA: Crushing or compressing the nerve
• CRHONIC PAIN
– Causalgia: Burning pain
• Appears 1-2 weeks after injury to either brachial
• plexus, medial or sciatic nerves.
• Pain triggered by light touch, sound or cold.
• Discoloration to the extremity, texture changes in the skin.
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SOME OF THE SPECIFIC
PROBLEMS continued
– Reflex Sympathetic Dystrophy (RSD)
• Occurs after peripheral
• nerve injury
• Associated with vasomotor change; vasospasm.
• Vasodilation > vasoconstriction
• Cool cyonotic and edematous extremities lead to muscle wasting - amputation
SOME OF THE SPECIFIC
PROBLEMS continued
• PLEXUS INJURY
– May be complete or partial
– Involves the nerve plexus distal to the spinal roots but proximal to the formation of the peripheral nerves
– Etiology: Trauma, compression or infiltration.
– Clinical manifestations: Motor weakness, muscle atrophy and sensory loss.
Complete plexus injury results in paralysis
NURSING PROCESS
Neuropathic pain is not only chronic and intractable, it is debilitating and causes extreme physical, psychological and social distress.
• The nurse must assess the type of nerve involved and the symptoms associated with it
• What impact does this have on the patient ’s life?
NURSING PROCESS
• Identify the nursing diagnosis (Pain is the obvious one, but others??)
• Outcomes will need to be realistic, i.e., “will be free of pain” is not usually achieved in the short time, if ever
• Interventions
– Medical vs. Independent Nursing
Actions
MEDICAL
• Nerve blocks
• Nerve stimulation
• Surgical decompression of the nerve
• Medications
– NSAIDS
– Anticonvulsants
– Narcotics
NURSING
• Administering medications
• Treatments
– Massage
– Ice/heat
– Relaxation/distractio n
• Adaptation
• Empathy
CRANIAL NERVE DISORDERS
Ready for some more “happy” news??
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TIC DOULOUREUX
• DEFINED: A disorder of unilateral (usually right-sided) facial pain
• commonly occur in persons over the age of
50, and affect women more often than men
• unilateral pain attacks that start abruptly and last for varying periods of time from minutes to hours
• pain quality is usually sharp, stabbing, lancinating (cutting or tearing), and burning.
It may have an "electric shock"-like character
• Attacks are initiated by stimuli such as light touch of the skin, chewing, washing the face, and brushing the teeth
• Irritation results from damage due either to changes in the blood vessels or the presence of a tumor or other lesions that cause compression of the nerve
• Maxillary and mandibular branches are most effected
Trigeminal Neuralgia - Etiology
• Many cases the etiology is unknown
– Intrinsic – lesion within nerve
– Extrinsic – lesion external to the trigeminal ganglion
• Tumor
• Vascular irregularities
– Other common contributing factors
• Dental work
• Aging process
• Digitalis intoxication
PATHOPHYSIOLOGY
• Is the problem within the nerve itself? Intrinsic
• Is the problem caused by something outside the nerve? Extrinsic
• Historically; the patho. Was believed to be primarily intrinsic; a sudden firing of neurons
• Currently; the belief is that the nerve is irritated by something extrinsic
• For some patients the cause is uncertain
CLINICAL MANIFESTATIONS
When asked about her pain, she describes it as being like:
"an ice pick chipping the teeth... ants nibbling in her nose... razor blades slashing her cheek... fire-red poker branding her face... electric-shock sparks in her cheek... needles pricking her eye... and lightning bolts splitting through her head."
Neurosurgeons say it is the most excruciating pain known to man
MEDICAL MANAGEMENT
• Medications
– Anticonvulsants (usually the most effective) and antidepressants (particularly effective for atypical forms) are routinely given in various combinations
– Anti-spasticity drugs are somewhat related to anticonvulsants, but act on the muscles rather than the nerves themselves
– NSAIDS and Narcotics ; even moderately strong opiates often do not help, let alone over-thecounter NSAIDS
– Experimental treatments are being conducted, using medications approved for other medical problems
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SURGICAL INTERVENTION
•
Nerve Blocks , a local anesthetic is injected near the nerve, either at the root or at a peripheral site. Can help stop a sudden, severe TN attack. Can be repeated. Does not give permanent relief
• Microvascular Decompression , if TN is caused by a small blood vessel constricting the nerve near its root, TN can often be effectively treated by MVD. An operation in which the blood vessel is carefully separated from the nerve. MVD is a major and difficult surgical operation
• Rhizotomy refers to a small lesioning of the nerve, the lesion blocks the pain impulse, causung pain relief without side effects. However, a frequent side effect is partial or total numbness of the affected side of the face
What does the nurse consider when developing a plan???
• Pain
• Emotional support
• Hygiene
• Nutrition
• Teaching
• Prevent post-op. complications
BELL ’S PALSY
• Defined; What Nerve?? What happens to the patient ’s eye lid when one has
BP?
• Etiology; Occurs when the facial nerve is swollen, inflamed, or compressed, resulting in facial weakness or paralysis.
Exactly what causes this damage, however, is unknown.
• Epidemiology;
– 40,000 Americans each year
– men and women equally
– any age, but it is less common before age
15 or after age 60
– It disproportionately attacks pregnant women and people who have diabetes or upper respiratory ailments such as the flu or a cold
BELL
’S PALSY pathophysiology
• Lesion in the nerve
• Injury to the nerve
• Dysfunction due to ischemia
• Regeneration
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BELL ’S PALSY Clinical
Manifestations
• sagging face
• sagging mouth, drooling
• inability to wrinkle forehead symmetrically, raise eyebrow, smile, whistle or grimace.
• inability to close eyelid , abnormal tearing, loss of corneal reflex
• pain in ipsilateral ear decreased taste on anterior 2/3 tongue decreased salivation
BELL ’S PALSY medical management
• Symptoms usually subside on their own within 2 weeks
– Steroids – very common (Prednisone)
– Analgesics – for pain (if present)
– AntiVirals (Acyclovir) in combo with steroids
– Vitamins (B’s 1,6 and 12)
EYE CARE
• Bell's palsy can interrupt the eyelid's natural blinking ability, leaving the eye exposed to irritation and drying. Therefore, keeping the eye moist and protecting the eye from debris and injury, especially at night, is important.
Lubricating eye drops, such as artificial tears or eye ointments or gels, and eye patches are also effective.
Nursing Process ..this patient may be in ER or on the unit for other problems …not hospitalized for Bell
’s Palsy exclusively.
So, Assess, Identify primary problems
…
• NUTRITION
Liquids are difficult!
• PSYCHOSOCIAL
Body image
The nurse will provide the prescribed medications and can also encourage facial exercises, warm compresses and massage. The nurse will need to provide and opportunity for therapeutic communication too.
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N242
OBJECTIVES: By the end of this learning experience, the student will be able to:
1. Describe the source and role of the hormones of the neuroendocrine system.
2. List the causes for imbalances within the neuroendocrine system.
3. Identify the diagnostic tests used to determine alterations in neuroendocrine function.
4. Discuss the major imbalances of the neuroendocrine system including the thyroid, , adrenals and pituitary gland.
5. Utilize the nursing process to make assessments on patients with disorders of the neuroendocrine system.
6. Specify the teaching needs of patients requiring hormonal therapy.
7. Explain the hypothalamic - pituitary loop.
8. Differentiate between Diabetes Insipidus and Syndrome of Inappropriate ADH; pathophysiology, clinical manifestations and nursing considerations.
Critical Thinking Activity
1. Discuss the difference between Addison’s Disease and Cushings’s syndrome.
CUSHING’S pathophysiology
ADDISON’S manifestations interventions
2. Discuss the difference between diabetes insipitus and Syndrome of Inappropriate ADH
DI pathophysiology manifestations interventions
SIADH
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N242
OBJECTIVES: By the end of this learning experience, the student will be able to:
1. Identify anatomical features of the eye.
2. Specify diagnostic tests used in assessing eyes and vision
3. Use the nursing process as a framework for care of the patient with glaucoma.
4. Describe the emergency care of patients who have sustained traumatic eye injury.
2.
5. Describe the nursing interventions utilized for a patient with limited vision.
Critical Thinking Activity
1. You have a visually impaired patient. Name three specific nursing interventions for this patient.
You are the advice nurse at a local urgent care center. A woman calls up requesting how to care for her boyfriend who just splashed anti-freeze in his eyes. What would you recommend?
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N242
HEALTH CARE CONTEMPORARY ISSUES
Self Study
OBJECTIVES :
By the end of this learning experience, the student will be able to:
1. Evaluate the key issues that currently are affecting health care trends. a. b. c. d. political process regulatory agencies professional organizations societal trends
2. Identify one way nursing can benefit from the current changes in health care.
Critical Thinking activity:
If you could have three wishes that would change health care, what would you wish for?
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PROFESSIONAL TRENDS
OBJECTIVES:
By the end of this learning experience, the student will be able to:
1. Differentiate between clinical and managerial tracks in nursing.
2.
Self Study
3.
Delineate input structures that affect professional trends (consumerism, licenser and credentialing, practice acts, politics).
Discuss the current employment opportunities (minimal requirements for employment and job description).
NURSING CARE OF THE
PATIENT WITH NEURO-
ENDOCRINE DISORDERS
REVIEW
• The pituitary gland is often portrayed as the "master gland" of the body.
Such praise is justified in the sense that the anterior and posterior pituitary secrete a battery of hormones that collectively influence all cells and affect virtually all physiologic processes.
• The pituitary gland may be king, but the power behind the throne is clearly the hypothalamus
– neurons within the hypothalamus neurosecretory neurons - secrete hormones that strictly control secretion of hormones from the anterior pituitary. The hypothalamic hormones are referred to as releasing hormones and inhibiting hormones , reflecting their influence on anterior pituitary hormones.
HORMONES
• The “active ingredients” in the body that assist the nervous system in making things happen …at the target organs
• Hormones are secreted by endocrine glands, scattered through out the body
• We will look at Thyroid and the Adrenal systems as they relate to disorders found in the hypothalmus/pituitary gland
131

WHERE IS THE PROBLEM IN THE “LOOP”
• PRIMARY = the endocrine gland itself
(I.e., the thyroid gland)
• SECONDARY = Pituitary gland
• TERTIARY = Hypothalmus
THYROID HORMONES
• TSH released from Pituitary
• Causes the thyroid to release T4, T3 and calcitonin (controlled by calcium levels in the body, not by negative feedback through the pituitary)
– T4 = Thyroxine  maintains body metabolism
– T3 = Tri-iodo-thy-ro-nine  5X more potent than T4  regulates metabolism
HYPERTHYROIDISM
• If it is primary, we call this Graves disease, an autoimmune disorder
• AKA hyperthyroidism if secondary or tertiary
• Pathophysiology = Excessive thyroid hormone
HYPERTHYROIDISM
• Clinical Manifestations:
– Nervousness, hyperexcitability
– Irritable
–  ’s in ; pulse, sweating, appetite (without weight gain)
– Hand tremors, bulging eyes
• Symptoms may be mild with remissions and exacerbations; out of control = heart failure
THYROID STORM
Begins with a stressor
 could be after thyroid surgery, during an exam (of the thyroid)
 
HR (+130),

Temp., other systemic disturbances; diarrhea, psychosis,chest pain
 must be treated or result will be death
  temp with cooling blankets, Tylenol

PTU ( Propylthiouracil
Pronunciation: Proe pil thye oh YOOR a sil
)
 hydrocortisone for shock
 meds for arrhythmias

Iodine will

T4 output
DIAGNOSTICS
• Levels of the thyroid hormones themselves,
T4 and T3 are measured in blood and one or both must be high for this diagnosis to be made. (Iodine reuptake)
• It is also useful to measure the level of thyroid-stimulating hormone (TSH)
• Differentiates between primary and secondary /tertiary
• Scans are helpful too
• Palpate … check your thyroid gland
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THERAPEUTIC INTERVENTIONS
• May treat the symptoms (palpitations = beta blockers)
• methimazole (Tapzole) and propylthiouracil
(PTU) both of which actually interfere with the thyroid gland's ability to make its hormones
• Radioactive iodine is the most widely recommended permanent treatment of hyperthyroidism  a poisonous type of radiation, the thyroid cells which absorb it will be damaged or killed
THERAPEUTIC INTERVENTIONS
• Another permanent cure for hyperthyroidism is to surgically remove all or part of the gland
 careful thyroid storm!!
SO WHAT IS THE NURSES
CONCERN?
• Identify stressors, help with minimizing these
• Nutrition  carbs/protein and avoid stimulants
• Post-op
– Watch for sx.s of storm
– Hematoma
– Good neck alignment
HYPOTHYROIDSM
• OKAY….IT’S THE OPPOSITE!
• If it is primary, we call this Hoshimoto’s
Thyroiditis …where the immune system attacks the thyroid gland
• May be the result of older age (women especially) or post radiation or surgical excision of the gland itself
• Diagnostics = blood tests (same as for hyperthyroidism)
• Clinical manifestations; fatigue, activity intolerance, constipation,  body temperature.
• Severe sx.s = Alt. Resp., CAD, Altered thought processes ….Myxedema (severe hypothyroidism)
• Treatments; hormone replacement
– (Levothyroxine) once a day, a pure synthetic form of T4
• Nursing: Don’t forget to take the pill!!!
ADRENAL / PITUITARY
• Adrenal is divided by cortex and medulla
– The cortex =
• glucocorticoids  metabolism and break down of fats/proteins, antagonizes insulin, emotional function and suppresses inflammatory response
• Mineral corticoids  water/sodium
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PATHOPHYSIOLOGY OF
HYPER-FUNCTION
Since cortisol production by the adrenal glands is normally under the control of the pituitary (like the thyroid gland), overproduction can be caused by a tumor in the pituitary or within the adrenal glands themselves. When a pituitary tumor secretes too much ACTH
(Adrenal Cortical Tropic Hormone), it simply causes the otherwise normal adrenal glands to produce too much cortisol.
CLINICAL MANIFESTATIONS
• Due to  in glucocorticoids and androgens
 buffalo hump, heavy trunk, thin extremities, fragile skin, sleep disturbances, water/sodium retention, 
BP, CHF, moon face,oily skin ….
DIAGNOSTICS AND
TREATMENT
• Cortisol levels/ 24hour urine collection
• Scans of both Pituitary and or Adrenal
• Blood levels; to differentiate between primary and secondary (glucocorticoids vs. ACTH)
• Treatment: Related to Pituitary tumors  transphenoidal surgery
• Need to replace hormones; for life if the whole gland was removed
NURSING
• Self care deficit
• Body image disturbances
• Altered thought processes
• Injury
• Infection
• Integumentary
HYPOFUNCTION - ADDISONS
• Opposite of Cushings!!
• Symptoms = muscular weakness, emaciation,
 blood glucose,
 sodium,  potassium, darkening of skin, hypotension, severe cases (when patients stop taking hormone replacement= sodium and water imbalances
• Nursing= fluid volume deficit, activity intolerance, knowledge deficit
Diabetes Insipidus (DI)
VS.
Syndrome of Inappropriate Anti-
Diuretic Hormone (SIADH)
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When do these occur??
DI
• When there is a deficiency of vassopressin
– Anti
Diuretic Hormone (ADH)
• Common with head trauma, brain tumors and surgery
– especially pituitary
SIADH
• When there is too much
ADH
• Common with malignancy, lung tumors small cell carcinoma makes it ’s own hormones → upsetting hormonal balance) and other diseases of the lung, head trauma – especially with hydrocephalus
Compare the collaborative management
DI
• This is usually transient
• Need to prevent dehydration
– matching intake and output
• Pharmacology:
DDAVP, Aqueous
Vasopressin (
↑
ADH)
• Priority N. DX.s??
SIADH
• Must treat the underlying cause
• Fluid restriction
(600-800ml/day)
• Declomycin ( ↓ ADH)
• Priority N. DX.s??
Okay
…here we go, to the last content area involving the body!!!!
EYES
WHAT YOU NEED TO KNOW
ABOUT THE EYES …
• Glaucoma; blindness related to
 intraoccular pressure
• Begins slowly with small areas of peripheral vision limitations, which may go unnoticed – OPEN ANGLE
• CLOSED ANGLE –produces pain and blurred vision; much more noticeable
• Must treat or go blind
MORE ….
• Needs to take the eye drops!!
• Encourage regular eye exams
• Trauma to eye – patch and an expert must remove object (if there is one)
• Chemical – irrigate for 15 minutes, continuous flush
Hang in there …..
Let ’s talk about trends…YOUR LAST
LECTURE CONTENT EVER IN THE
NURSING PROGRAM AT CSM …the count down time is really on!!
135

What is a trend??
• Patterns of change. For health care, these changes determine the direction of nursing and other health professions take. The information gathered on trends influences the options and career paths of health care professions, how health care is delivered and the consumer at large
Three key areas that will determine the future of health care
1. SERVICE
2. QUALITY
3. COST
Surviving the changes/challenges of health care
• NETWORK
• SET GOALS (education)
• ACCEPT CHANGE
Nursing Trends …
1. Where Art Thou, Nurse?
2. The Patient Safety Imperative
3. Skyrocketing Healthcare Costs
4. Born Earlier and Living Longer
5. Shorter Lengths of Hospital Stay
6. Healthcare Consumerism and "E-Health"
7. Complementary and Alternative Medicine
8. Technological Wonders and Woes
9. Web-Based Nursing Degrees
10. Disparities in Healthcare
11. Living With Chronic Disease
12. Return of the Plagues
•
As I enter the nursing profession, I solemnly swear to do my very best …
To prevent or cure my own and find a treatment for other
’s psychosclerosis
• To become flexible and accept change
• To register as a member of the LEXUS SOCIETY
– Loving
– Empathetic
– Xenophilic and
– Utterly serene
• To drop any affiliation to the BMW CLUB
–
Bitchers, Moaners and Whiners
• To achieve personal empowerment and not become a negaholic
• To love and respect myself first, so that I may be better able to love and respect others
•
• To talk out problems instead of acting out on them
To have
“RN” printed on my checks, so that I am constantly reminded how proud I am of this accomplishment
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