NUR 2755 Multidimensional Care IV
Exam 1 Blueprint
Iggy Chapter: Neurological-42, 43, 44, 45. Perioperative- 14, 15, 16
For all conditions you must understand the Pathophysiology, Clinical manifestations
including labs/diagnostics, Possible problems (nursing Diagnosis), interventions and
client teaching.
Alzheimer’s: microscopic changes of the brain – neurofibrillary tangles, neurotic plaques, beta
amyloid
Stages: steady and gradual decline of cognitive, mobility, and ADL function from milk
through severe stages; patients usually die from complications of immobility
o Early (Stage 1): First symptoms up to 4 years
Independent in ADLs
Denies presence of symptoms
Forgets names; misplaces household items
Has short-term memory loss and difficulty recalling new information
Shows subtle changes in personality and behavior
Loses initiative and is less engaged in social relationships
Has mild impaired cognition and problems with judgment
Demonstrates decreased performance, especially when stressed
Unable to travel alone to new destinations
Often has decreased sense of smell
o Middle (Stage 2): 2-3 years
Has impairment of all cognitive functions
Demonstrates problems with handling or unable to handle money and
finances
Is disoriented to time, place, and event
Is increasingly dependent in ADLs
Has visuospatial deficits: has difficulty driving and gets lost
Has speech and language deficits: less talkative, decreased us of
vocabulary, increasingly nonfluent, and eventually aphasic
Incontinent
Psychotic behaviors such as delusions, hallucinations, and paranoia
Has episodes of wander; trouble sleeping
o Late (Stage 3)
Completely incapacitated; bedridden
Totally dependent in ADLs
Has loss of mobility and verbal skills
Possibly has seizures and tremors
Has agnosia (loss of sensory comprehension including facial recognition)
Etiology: UNKNOWN
o Increased age over 65 years
o Female more prone
o Down syndrome
o TBI
o African Americans and Hispanics
Safety Considerations
o Prevent injury, wandering, or falls: ID badge or bracelet
o Aggressiveness, especially verbal and physical abusive tendencies: keep patient
busy with structured activities
o Rapid mood swings
o Increased confusion at night or when light is not adequate or in excessively
fatigued patients
o Remove or secure all potentially dangerous objects
o Seizure precautions
o Environment must be uncluttered, consistent, and structured
o When in hospital, avoid the use of restraints including side rails, frequent
surveillance, toileting every 2 hours
Caregiver support
o Teach caregivers to be aware of their own health and stress levels
o Respite care: give caregivers a break
o Prevent elder abuse
o When a problem behavior occurs, divert patient to another activity; minimize
excessive stimulation
o Alzheimer’s association
Orientation vs validation
o Orient to time, place, and person during early stages
Does not work for moderate or severe AD – use validation instead to
prevent agitation
o Validation: recognizes and acknowledges the patient’s feelings and concerns
Routines
o Establish a daily routing and follow it as much as possible
o Explain changes in routine to the patient before they occur, repeating the
explanation immediately before the changes take place
o Establish exercise program to maintain mobility for as long as possible and to
prevent complications of immobility
o Encourage to be as independent as possible in ADLs
Medication Therapy
o Cholinesterase inhibitors – delay destruction of ACh
o NMDA receptor antagonist – blocks excess glutamate
o Antidepressants (SSRI) – no tricyclics because of side effects
o Psychotropic drugs – reserved for hallucinations, last resort and should be lowest
dose possible
Parkinson’s
Pathophysiology: progressive neurodegenerative disorder. Chronic, terminal disease
caused by degeneration of substantia nigra cells in the basal ganglia of the brain
causing decreased dopamine, which normally functions to promote voluntary muscle
and sympathetic nervous system control
o Symptoms: tremor (in upper extremity), muscle rigidity (cogwheel, plastic, lead
pipe), bradykinesia (slow movement/no movement), postural instability
Emotional changes
Speech changes
Bowel and bladder changes
Slow and gradual decline (10-20 years) – usually die from complications of
immobility
Etiology: environmental and genetic factors, exposure to chemicals and metals, older
than 40, familial tendency
o Primary disease: cause not known, but could be a combination of genetic and
environmental factors
Male
Over 40 years
Family history
o Secondary disease: caused by antipsychotic drugs or another condition such as
brain tumor or trauma
Stages
o Initial stage: unilateral limb involvement, minimal weakness, hand and arm
trembling
o Mild stage: bilateral limb involvement, masklike face, slow and shuffling gait
o Moderate disease: postural instability, increased gait disturbance
o Severe disability: akinesia, rigidity
o Stage 5: complete ADL dependence
Fall Prevention intervention
Dealing with clinical manifestations
o Decreased mobility related to muscle rigidity, tremors, and postural/gait changes
Exercise, PT
Surgical: stereotactic pallidotomy, deep brain stimulation
o Impaired cognition due to neurotransmitter changes in the brain
NUR 2755 Multidimensional Care IV
Exam 2 Blueprint
Burns – thermal, chemical, smoke inhalation, electrical, cold thermal
Risk factors
o Older adults heal more slowly than young adults
o Preexisting cardiovascular, respiratory, and renal disease cause for poorer
prognosis
o Diabetes mellitus contributes to poor healing and gangrene
o Physical debilitation: alcoholism, drug abuse, malnutrition
o Concurrent fractures, head injuries, or other trauma also lead to poor prognosis
Electrical burns – result from coagulation necrosis caused by intense heat generated
from an electrical current
o May result from direct damage to nerves and vessels causing tissue anoxia and
death
o Severity depends on amount of voltage, tissue resistance, current pathways,
surface area, duration of the flow
o Current that passes through vital organs will produce more life-threatening
sequelae than current passing through other tissue
o Electrical sparks may ignite the patient’s clothing, causing a combination of
thermal and electrical injury
o Severity of injury can be difficult to assess as most damage is beneath the skin
(iceberg effect)
o At risk for dysrhythmias, severe metabolic acidosis, myoglobinuria
Chemical burn – acids, alkalis, organic compounds
o Pre hospital care
Brush solid particles off the skin
Water lavage
Remove clothing over chemical burn ASAP
Tissue destruction may continue up to 72 hours after a chemical injury
Identify chemical for specific treatment
Monitor for systemic toxicity
o Alkali burns are hard to manage because they cause protein hydrolysis and
liquefaction – damage continues after alkali is neutralized
o Injuries to skin, respiratory system, liver, kidney, eye (severe corneal scarring)
Smoke inhalation injuries – result from inhalation of hot air or noxious chemicals
o Causes damage to respiratory tract
o Major predictor of mortality in burn victims – need to be treated quickly
o Carbon monoxide poisoning displaces oxygen
Hypoxia
Carboxyhemoglobinemia
Death
o Inhalation injury above the glottis
Thermally produced, hot air, steam, or smoke
Mucosal burns of oropharynx and larynx
Mechanical obstruction can occur quickly
o Inhalation injury below the glottis
Injury is related to length of exposure to smoke or toxic fumes
Pulmonary edema may not appear until 12 to 24 hours after the burn –
acute respiratory distress syndrome
Assessment – Expected laboratory values – stages
Treatment – Fluids – skin grafts – Fluid overload S&S
Phase of Burn Injury management
o Prehospital care
Remove the person from the source of the burn and stop the burning
process
Rescuer must be protected from becoming part of the incident
Electrical injuries – remove patient from contact with source
Chemical injuries – brush soli particles off the skin and water lavage
Small thermal burns – cover with clean, cool, tap water dampened towel
Large thermal burns – airway, breathing, and circulation
Do not immerse in cool water or pack with ice
Wrap in clean, dry sheet or blanket
Remove burned clothing
o Emergent/Resuscitative Phase – required to resolve the immediate problems
resulting from injury, usually lasts 24-48 hours
Fluid loss and edema formation and continues until fluid mobilization and
diuresis begin
Fluid and electrolyte shifts
Greatest threat is hypovolemic shock caused by a massive shift of
fluids out of blood vessels as a result of increased capillary
permeability
Colloidal osmotic pressure decreases resulting in more fluid shifting
out of the vascular space into the interstitial spaces
Net result of the fluid shift is intravascular volume depletion –
edema, decreased BP, increased pulse
Normal insensible loss: 30-50 ml/hr
Severely burned patient 200-400 ml/hr
RBCs are hemolyzed by a circulating factor released at the time of
the burn
Thrombosis
Elevated hematocrit
Immunologic changes
Burn injury causes widespread impairment of the immune system
because the skin barrier is destroyed
Decreased circulating levels of immunoglobulins
WBC changes
Cardiovascular system
Dysrhythmias and hypovolemic shock, edema, ischemia, necrosis,
paresthesia, gangrene
Impaired microcirculation and increased viscosity -> sludging
Respiratory system
Upper respiratory tract injury causes edema formation and
mechanical airway obstruction and asphyxia
Inhalation injury
o Direct insult at the alveolar level
o Interstitial edema
o Patient may not exhibit signs during first 24 hours
Pneumonia
Pulmonary edema
Urinary system
Decreased blood flow to kidneys causes renal ischemia
Acute tubular necrosis
Nursing management
Fluid therapy
o One or two large-bore IV lines
o Type of fluid replacement based on size/depth of burn, age,
and individual consideration
o Parkland (Baxter) formula
o Colloidal solutions
Airway management: early endotracheal intubation, escharotomies
of the chest wall, fiberoptic bronchoscopy, humidified air and 100%
oxygen
Wound care
o Should be delated until a patient airway, adequate
circulation, and adequate fluid replacement have been
established
NUR 2755 Multidimensional Care IV
Final Exam Blueprint
Neuro 25%
1) Alzheimer’s
a. Stages
b. Safety considerations
c. Caregiver support
i. Assess the needs of the caregiver and provide realistic expectations
ii. Respite care
d. Orientation vs Validation
i. Orientation for mild AD
ii. Validation for moderate or severe AD – recognizes and
acknowledges the patient’s feelings and concerns
e. Routines: establish a daily routine
2) Parkinson’s: decreased dopamine which normally functions to promote voluntary
muscle and sympathetic nervous system control
a. Clinical manifestations: tremor, muscle rigidity, bradykinesia, postural
instability
b. Fall prevention intervention
3) Meningitis
a. S/S: nuchal rigidity, fever, flu-like symptoms
b. Tier 2 precautions: droplet
c. Lumbar puncture teaching
i. Keep patient lying flat for several hours
ii. Complications: headache, CSF leakage
d. Complication: increase ICP can lead to herniation of the brain and death –
treat with mannitol
e. Kernig (knee extension is painful) & Brudzinski (neck flexion leads to knee
flexion) signs
4) Seizures
a. Types
i. Atonic: sudden loss of muscle tone, confusion afterwards, lasts a
few seconds, resistant to medications
ii. Myoclonic: brief jerking of extremities, lasts a few seconds
iii. Tonic: abrupt increase of muscle tone, lost of consciousness,
autonomic changes (apnea, dysrhythmia, incontinence, drooling),
lasts 30 seconds to several minutes
iv. Clonic: muscle contraction and relaxation that lasts several minutes
v. Tonic-clonic: stiffness and loss of consciousness to jerking
extremities that lasts 2-5 minutes
- Incontinence, fatigue, acute confusion, bite tongue
- Postictal: >1hr, confusion, fatigue, agitation
vi. Complex partial: syncope, wandering, amnesia
vii. Simple partial: maintains consciousness, altered sense of smell,
auras, autonomic changes, sudden pain response, potential onesided extremity jerking
viii. pseudo-seizures
b. Aura: unusual sensation before seizure takes place
c. Postictal
i. Monitor VS, reorientation, keep on side, have suction and O2
available, neuro checks, identify presence of aura and trigger
d. Actions to take/avoid when seizure occur
i. Lower pt to floor, turn on side to prevent aspiration, loosen
clothing, time seizure
e. Seizure precautions: padded side rails, siderails up, suction and O2 near
bed, IV access
f. Status epilepticus
i. Seizures lasting more than 5 minutes or repeated seizing prior to
the postictal phase and no regaining consciousness between
seizure
ii. Treat with benzo: diazepam, lorazepam
g. Medication teaching
i. DMV – notify DMV of seizure disorder
ii. Phenytoin sodium side effects
iii. Take meds on time and consistently
5) Increase ICP