NUR 121

NUR 12O Neurological Disorders Cerebrovascular Accident SeizuresGlaucomaCataractsRetinal DetachmentEye TraumaEar Disorders

The Brain and its lobe/functions The cerebrum or cortex is the largest part of the human brain, associated with higher brain function such as thought and action.Frontal Lobe- associated with reasoning, planning, parts of speech, movement, emotions, and problem solving Parietal Lobe- associated with movement, orientation, recognition, perception of stimuli Occipital Lobe- associated with visual processing Temporal Lobe- associated with perception and recognition of auditory stimuli, memory, and speech.

The Brain and its lobe functionsRight hemisphere is associated with creativity and the left hemispheres is associated with logic abilities. The corpus callosum is a bundle of axons which connects these two hemispheres. The Cerebellum - This structure is associated with regulation and coordination of movement, posture, and balance. Limbic System - referred to as the "emotional brain", is found buried within the cerebrum. This system contains the thalamus, hypothalamus, amygdala, and hippocampus.

The Brain and its lobe/functionsBrain Stem - Underneath the limbic system is the brain stem. This structure is responsible for basic vital life functions such as breathing, heartbeat, and blood pressure.

The AmygdalaIt's name is latin for almond which relates to its shape. It helps in storing and classifying emotionally charged memories. It plays a large role in producing our emotions, especially fear. It's been found to trigger responses to strong emotion such as sweaty palms, freezing, increased heart-beat/respiration and stress hormone release.

Cerebrovascular AccidentAlso known as strokeInvolve a disruption in cerebral blood flow related to ischemia, hemorrhage or embolism.

Stroke affects 700,000 people every year and 160,000 Americans die of stroke each year

Stroke is the sudden stoppage of blood flow.5DescriptionSudden loss of brain function resulting from a disruption in the blood supply to a part of a brain.

CLASSIFICATION:ThromboticHemorrhagic

CNS involvement related to cause of CVAHemorrhagic cause by a slow or fast hemorrhage into the brain tissue into the brain tissue: often related to hypertension.

Embolytic caused by a clot that has broken away (embolus) from a vessel and has lodge in one of the arteries of the brain, blocking blood supply. It is often related to atherossclerosis. CVA PathophysiologyBrain cells need oxygen and nutrients to work properly.

This nourishment is provided from blood flowing through vessels in the brain.

When one of these vessels becomes clogged by a clot, or breaks open, the blood flow is suddenly stopped and the brain cells die.

This is a stroke.

Cerebrovascular Accident

Risk FactorsHypertensionAtherosclerosisHyperlipidemiaDiabetes MillitusCocaine UseAtrial fibrillationSmokingUse of Oral ContraceptivesObesityHypercoagilabilityCerebral AneurysmArteriovenous Malformation

What risk factors for stroke can't be changed?Age The chance of having a stroke approximately doubles for each decade of life after age 55. While stroke is common among the elderly, a lot of people under 65 also have strokes. Heredity (family history) and raceYour stroke risk is greater if a parent, grandparent, sister or brother has had a stroke. African Americans have a much higher risk of death from a stroke than Caucasians do. This is partly because blacks have higher risks of high blood pressure, diabetes and obesity. Sex (gender) Stroke is more common in men than in women. In most age groups, more men than women will have a stroke in a given year. However, more than half of total stroke deaths occur in women. At all ages, more women than men die of stroke. Use of birth control pills and pregnancy pose special stroke risks for women. Prior stroke, TIA or heart attack The risk of stroke for someone who has already had one is many times that of a person who has not.Transient ischemic attacks (TIAs) are "warning strokes" that produce stroke-like symptoms but no lasting damage. TIAs are strong predictors of stroke. A person who's had one or more TIAs is almost 10 times more likely to have a stroke than someone of the same age and sex who hasn't. Recognizing and treating TIAs can reduce your risk of a major stroke. If you've had a heart attack, you're at higher risk of having a stroke, too. TIA should be considered a medical emergency and followed up immediately with a healthcare professional. What stroke risk factors can be changed, treated or controlled?High blood pressure High blood pressure is the leading cause of stroke and the most important controllable risk factor for stroke. Many people believe the effective treatment of high blood pressure is a key reason for the accelerated decline in the death rates for stroke. Cigarette smoking In recent years, studies have shown cigarette smoking to be an important risk factor for stroke. The nicotine and carbon monoxide in cigarette smoke damage the cardiovascular system in many ways. The use of oral contraceptives combined with cigarette smoking greatly increases stroke risk. Diabetes mellitus Diabetes is an independent risk factor for stroke. Many people with diabetes also have high blood pressure, high blood cholesterol and are overweight. This increases their risk even more. While diabetes is treatable, the presence of the disease still increases your risk of stroke. Carotid or other artery disease The carotid arteries in your neck supply blood to your brain. A carotid artery narrowed by fatty deposits from atherosclerosis(plaque buildups in artery walls) may become blocked by a blood clot. Carotid artery disease is also called carotid artery stenosis. Peripheral artery disease is the narrowing of blood vessels carrying blood to leg and arm muscles. It's caused by fatty buildups of plaque in artery walls. People with peripheral artery disease have a higher risk of carotid artery disease, which raises their risk of stroke. Atrial fibrillation This heart rhythm disorder raises the risk for stroke. The heart's upper chambers quiver instead of beating effectively, which can let the blood pool and clot. If a clot breaks off, enters the bloodstream and lodges in an artery leading to the brain, a stroke results. Other heart disease People with coronary heart disease or heart failure have a higher risk of stroke than those with hearts that work normally.Dilated cardiomyopathy (an enlarged heart), heart valve disease and some types of congenital heart defects also raise the risk of stroke. Sickle cell disease (also called sickle cell anemia) This is a genetic disorder that mainly affects African-American and Hispanic children. "Sickled" red blood cells are less able to carry oxygen to the body's tissues and organs. These cells also tend to stick to blood vessel walls, which can block arteries to the brain and cause a stroke. High blood cholesterol People with high blood cholesterol have an increased risk for stroke. Also, it appears that low HDL (good) cholesterol is a risk factor for stroke in men, but more data are needed to verify its effect in women. Poor diet Diets high in saturated fat, trans fat and cholesterol can raise blood cholesterol levels. Diets high in sodium (salt) can contribute to increased blood pressure. Diets with excess calories can contribute to obesity. Also, a diet containing five or more servings of fruits and vegetables per day may reduce the risk of stroke. Physical inactivity and obesityBeing inactive, obese or both can increase your risk of high blood pressure, high blood cholesterol, diabetes, heart disease and stroke.So go on a brisk walk, take the stairs, and do whatever you can to make your life more active.Try to get a total of at least 30 minutes of activity on most or all days. What are other, less well-documented risk factors?Geographic location Strokes are more common in the southeastern United States than in other areas. These are the so-called "stroke belt" states. Socioeconomic factors There's some evidence that strokes are more common among low-income people than among more affluent people. Alcohol abuse Alcohol abuse can lead to multiple medical complications, including stroke. For those who consume alcohol, a recommendation of no more than two drinks per day for men and no more than one drink per day for nonpregnant women best reflects the state of the science for alcohol and stroke risk. Drug abuse Drug addiction is often a chronic relapsing disorder associated with a number of societal and health-related problems. Drugs that areabused, including cocaine, amphetamines and heroin, have been associated with an increased risk of stroke. Strokes caused by drug abuse are often seen in a younger population.

High blood pressure. High blood pressure, also called hypertension, can greatly increase your risk for stroke. Smoking cigarettes, eating a diet high in salt, and drinking too much alcohol can all raise your blood pressure.High blood cholesterol. High blood cholesterol can build up fatty deposits (plaque) on blood vessel walls. The deposits can block blood flow to the brain, causing a stroke. Diet, exercise, and family history affect blood cholesterol levels.Heart disease. Common heart disorders can increase your risk for stroke. For example, coronary artery disease (CAD) increases your risk because a fatty substance called plaque blocks the arteries that bring blood to the heart. Other heart conditions, such as heart valve defects, irregular heartbeat (including atrial fibrillation), and enlarged heart chambers, can cause blood clots that may break loose and cause a stroke.Diabetes. Having diabetes can increase your risk of stroke and can make the outcome of strokes worse. Diabetes is a condition that causes blood to build up too much sugar instead of delivering it to body tissues. High blood sugar tends to occur with high blood pressure and high cholesterol.Overweight and obesity. Being overweight or obese can raise total cholesterol levels, increase blood pressure, and promote the development of diabetes.Previous stroke or transient ischemic attack (TIA). If you have already had a stroke or a TIA, also known as a "mini-stroke," there is a greater chance that you could have a stroke in the future.Sickle cell disease. This is a blood disorder that is associated with ischemic stroke, and mainly affects African-American and Hispanic children. A stroke can happen if sickle cells get stuck in a blood vessel and clog blood flow to the brain. About 10% of children with sickle cell disease will have a stroke.

10What risk factors for stroke can't be changed?Age The chance of having a stroke approximately doubles for each decade of life after age 55.Heredity (family history) and race Stroke risk is greater if a parent, grandparent, sister or brother has had a stroke. African Americans have a much higher risk of death from a stroke than Caucasians do. This is partly because blacks have higher risks of high blood pressure, diabetes and obesity. Sex (gender) Stroke is more common in men than in women. More men than women will have a stroke in a given year. However, more than half of total stroke deaths occur in women. Use of birth control pills and pregnancy pose special stroke risks for women. Prior stroke, TIA or heart attack The risk of stroke for someone who has already had one is many times that of a person who has not.

High blood pressure High blood pressure is the leading cause of stroke and the most important controllable risk factor for stroke.Cigarette smoking- The nicotine and carbon monoxide in cigarette smoke damage the cardiovascular system. The use of oral contraceptives combined with cigarette smoking greatly increases stroke risk. Diabetes mellitus Diabetes is an independent risk factor for stroke. Carotid or other artery disease The carotid arteries in the neck supply blood to the brain. A carotid artery narrowed by fatty deposits from atherosclerosismay become blocked by a blood clot. Carotid artery disease is also called carotid artery stenosis. Peripheral artery disease is the narrowing of blood vessels carrying blood to leg and arm muscles. It's caused by fatty buildups of plaque in artery walls.What stroke risk factors can be changed, treated or controlled?Other contributing factorsAtrial fibrillationThe heart's upper chambers quiver instead of beating effectively, which can let the blood pool and clot.Sickle cell disease (also called sickle cell anemia) This is a genetic disorder that mainly affects African-American and Hispanic children. These cells tend to stick to blood vessel walls, which can block arteries to the brain and cause a stroke. High blood cholesterol People with high blood cholesterol have an increased risk for stroke.Poor diet Diets high in saturated fat, trans fat and cholesterol can raise blood cholesterol levels. Diets high in sodium (salt) can contribute to increased blood pressure.Physical inactivity and obesityBeing inactive, obese or both can increase your risk of high blood pressure, high blood cholesterol, diabetes, heart disease and stroke.What are other, less well-documented risk factors?Socioeconomic factors There's some evidence that strokes are more common among low-income people than among more affluent people. Alcohol abuse Alcohol abuse can lead to multiple medical complications, including stroke.Drug abuse Drugs that areabused, including cocaine, amphetamines and heroin, have been associated with an increased risk of stroke. Strokes caused by drug abuse are often seen in a younger population.

Diagnostic ProceduresMagnetic Resonance ImagingCT scanUsed to identify edema, ischemia and necrosis.MR Angiography or Cerebral Angiography used to identify the presence of cerebral hemorrhage, abnormal vessel structures, vessels ruptures, and regional perfusion of blood flow to the brain.Lumbar Puncture- is used to assess for presence of blood in the cerebrospinal fluid.Carotid Endarterectomy performed to open the artery by removing atheroscleroyic plaque.Interventional radiology is performed to treat cerebral aneurysm.

How is stroke diagnosed?In addition to a complete medical history and physical examination, diagnostic procedures for stroke may include the following.Imaging tests of the brain:computed tomography scan (Also called a CT or CAT scan.)-a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays; used to detect abnormalities and help identify the location or type of stroke.magnetic resonance imaging (MRI)-a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body; an MRI uses magnetic fields to detect small changes in brain tissue that helps to locate and diagnose stroke.radionuclide angiography-a nuclear brain scan in which radioactive compounds are injected into a vein in the arm, and a machine (similar to a Geiger counter) creates a map showing their uptake into different parts of the head. The images show how the brain functions rather than its structure. This test can often detect areas of decreased blood flow and tissue damage.computed tomographic angiography (CTA) - an x-ray image of the blood vessels. A CT angiogram uses CT technology to obtain images of blood vessels.magnetic resonance angiography (MRA) - - a procedure used to evaluate blood flow through arteries in a noninvasive (the skin is not pierced) manner using MRI technology.functional magnetic resonance imaging (fMRI) - - a variation of MRI used to determine the specific location of the brain where a certain function, such as speech or memory, occurs.Tests that evaluate the brain's electrical activity:electroencephalogram (EEG)-a procedure that records the brain's continuous, electrical activity by means of electrodes attached to the scalp.evoked potentials-procedures that record the brain's electrical response to visual, auditory, and sensory stimuli.Tests that measure blood flow:

Click Image to Enlargecarotid phonoangiography-a small microphone is placed over the carotid artery on the neck to record sounds created by blood flow as it passes through a partially blocked artery. The abnormal sound is called a bruit.Doppler sonography-a special transducer is used to direct sound waves into a blood vessel to evaluate blood flow. An audio receiver amplifies the sound of the blood moving though the vessel. Faintness or absence of sound may indicate a problem with blood flow.ocular plethysmography-measures pressure on the eyes, or detects pulses in the eyes.cerebral blood flow test (inhalation method)-measures the amount of oxygen in the blood supply that reaches different areas of the brain.digital subtraction angiography (DSA)-provides an image of the blood vessels in the brain detect a problem with blood flow. The test involves inserting a small, thin tube (catheter) into an artery in the leg and passing it up to the blood vessels in the brain. A contrast dye is injected through the catheter and x-ray images are taken.14Assessments:Symptoms will vary based on the area of the brain that is adequately supplied with oxygenated blood.The left cerebral hemisphere is responsible for language, mathematic skills, and analytic thinking. - aphasia (language use or comprehension difficulty) - Alexia (reading difficulty) loss of ability to read - Agraphia (writing difficulty) loss of ability to write - Apraxia inability to perform purposeful movement - Right hemiplegia or hemiparesis - Slow cautious behavior - Depression and quick frustration - Visual changes such ashemianopsia ( one side/eye unable to see. - Dysphagia dysfunctional swallowing15Assessments:He right hemisphere is responsible for visual and spatial awareness and proprioception. - unawareness of deficits (neglect syndrome, overestamation of abilities. - Loss of depth perception - Impulse-control difficulty - Disorientation - Poor judgment - Left hemiplegia or hemiparesis - Visual changes, such as hemianopsiaLocation of Disruption in the BrainFeatureLeft HemisphereRight HemisphereLanguageAphasiaAgraphiaMay be alert and orientedMemoryNo DeficitDisorientedCannot recognize facesVisionUnable to discriminate words and lettersReading problemsDeficit in right visual fieldVisual/* spatial deficitsNeglect of left visual fields* Loss of depth perception* Behavior* Slow, cautious, anxious when attempting new task, Depression or catastrophic response to illness, sense of guilt, feeling of worthlessness, worries over future, quick anger and frustrationImpulsive, unaware of neurologic deficits, confabulates, euphoric, constantly smiles, denies illness, poor judgment, overestimates abilities, impaired sense of humorHearing No deficit Loses ability to hear and tonal variationsAssess and Monitor: Nursing AssessmentChange in level of consciousnessParesthesia, paralysisAphasia, agraphia,Memory LossVisual ImpairmentBladder and Bowel dysfunctionBehavioral chnages

Airway patencySwallowing ability/aspiration riskLevel of consciousnessNeurological statusMotor functionSensory functionCognitive functionGlasgow Coma scale scoreAssessment of clients functional abilitiesMobilityActivity of daily livingEliminationCommunicationAbility to swallow, eat, and drink without aspirationStroke Assessment National Institutes of Health Stroke ScaleNIHSSDeveloped in 1983 by NIH stroke research neurologistsA Systematic tool designed to measure neuro deficits most often seen with strokeDesigned to standardize and document reliable and valid neuro examNIHHS Stroke ScaleNeed to be trained and certified to perform 11 itemsLess than 10 minutes to performRange of scores 0 42Lower score indicate less impairmentScore reflects what the patient does!!!NIHSS Stroke ScaleHelps to determine level of stroke severityGet points for deficits0 -1 Normal1 - 4 Minor Stroke5 - 15 Moderate Stroke15 - 20 Moderately Severe Stroke> 20 Severe StrokeNIHSS ScalePredicts outcome20 there is a 20% good outcome

Aids in planning rehabilitation needs 14 Severe: long term care6 13 Adequate: acute inpatient rehab 5 Mild: 80% discharged homeNIHSS Stroke ScaleAssessment Process General InstructionsAdminister items in order listedFollow directions for each examDo not coach patientRecord first answers after each subscale examDo not go back and change scores

1a. LOC1b. LOC Questions1c. LOC Commands2. Best Gaze3. Visual fields4. Facial palsy5. Motor Arm6. Motor Leg7. Limb ataxia8. Sensory9. Best Language10. Dysarthria11. Extinction & InattentionNIHSS Stroke ScaleLevel of ConsciousnessArousal0 = Alert1 = Not alert, but arousable2 = Not alert, repeated stimulation3 = Responds only with reflex motor to noxious stimuli

LOC QuestionsAwarenessMonth & age0 = Answer both questions1 = Answer one2 = Answer neitherNIHSS Stroke ScaleOpen & close eyes, grip and release hand0 = Performs both correct1 = Performs one correct2 = Performs neither

LOC PearlsMOST IMPORTANTSensitive indicator of cortical functionDecreased LOC only if both hemispheres/brainstem dysfunctionKey predictor of outcome

NIHSS Stroke ScaleBest GazeHorizontal eye movement0 = Normal1 = Partial gaze palsy (one or both eyes)2 = Forced deviation or total gaze paresis

Best Gaze PearlsCN VI longest intracranial courseFrequently involvedDouble vision maybe experiencedNIHSS Stroke ScaleVisual FieldsFinger counting or visual threat0 = No visual loss1 = Partial hemianopia2 = Complete hemianopia3 = Bilateral hemianopia (blindness)

Visual Fields PearlsInjury to Middle Cerebral ArteryOpposite side injuryStand on the RIGHT for Left MCAStand on the LEFT for Right MCANIHSS Stroke ScaleFacial PalsyShow teeth, raise eyebrows, close eyes0 = Normal1 = Minor paralysis (flattened nasolabial fold, asymmetry on smiling)2 = Partial paralysis (total/near total paralysis of lower face)3 = Complete paralysis, one or both sides (absence of movement in upper/lower face)

Facial Palsy PearlsSame side deficitEating is difficultDamage cornea unable to close eyeNIHSS Stroke ScaleMotor ArmLimb 45 supine, 90 sitting, drift if falls before 10 seconds0 = No drift1 = Drift (does not hit bed)2 = Some effort against gravity (drifts to bed)3 = No effort (limb falls)4 = No movementUN = Untestable

Motor Arm PearlsUnilateral deficit common with anterior cerebral injuryBilateral deficit common with brainstem injuryUnilateral arm drift common with MCA stroke

NIHSS Stroke ScaleMotor LegLimb 30, drift if falls before 5 seconds0 = No drift1 = Drift2 = Some effort against gravity3 = No effort4 = No movementUN = Untestable

Motor Leg PearlsUnilateral deficit common with anterior cerebral injuryBilateral deficit common with brainstem injuryUnilateral leg drift common with ACA strokeNIHSS Stroke ScaleLimb AtaxiaFinger-nose, heel shinScored only if present out of proportion to weakness0 = Absent (cannot understand, paralyzed)1 = Present in one limb2 = Present in two limbsUN = Untestable

Limb Ataxia PearlsDeficit may indicate cerebellar injuryNIHSS Stroke ScaleSensoryPinprickFace, arms, trunk, legsBilateral testing0 = Normal1 = Mild moderate loss (feels less sharp on affected side)2 = Severe total loss (not aware of being touched).

Sensory PearlsConsider parietal lobe injuryContralateral injury occursUnilateral neglect syndrome may be presentNIHSS Stroke ScaleBest LanguageDescribe pictures Read You know how, Down to earth, I got home from work, Near the table in the dining room, They heard him speak on the radio last night.Best Language0 = No aphasia1 = Mild-moderate aphasia (loss of fluency, can identify content from patient response)2 = Severe aphasia (fragmented expression, cannot identify content from patient response)3 = Mute, global aphasiaNANDA Nursing DiagnosisIneffective tissue perfusion (cerebral)Disturbed sensory perceptionImpaired physical mobilityUnilateral neglectRisk for injurySelf-care DeficitImpaired verbal communicationImpaired swallowingNursing Plans and Interventions Control hypertension to help prevent future CVA.Maintain proper body alignment while client is in bed. Use splints or other assistive devices. (including bed rolls and pillow) to maintain functional position.C. Position client to minimize edema, prevent contracture and maintain skin integrity.Perform full ROM exercises 4x a day. Follow up with program initiated by other team members.Instruct client to participate in or manage own personal care.

Nursing InterventionsMaintain a patent airwayMonitor for changes in clients LOC ( s/s of Increased ICP).Elevate the clients head to reduce ICP and to promote venous drainage. Avoid extreme flexion or extension, maintain the head in the midline neutral, and elevate the head of the bed to 30 degrees.Institute seizure precaution.Maintain a non-stimulating environment.Assist in communication skills if the clients speech is impaired. Consult a SLP (therapist).Assist with self-feeding - Assess swallowing reflexes, gag, cough before feeding. - The clients liquid may need to be thickened to avoid aspiration. - Have the client eat in an upright position and swallow with the head and neck flexed slightly forward.Nursing InterventionsAssist with feeding.Place food in the back of the mouth on the unaffected side.Suction on standby.Maintain a distraction free environment during meals.Maintain skin integrity. - Reposition the client frequently, use padding. - Monitor bony prominences, paying attention particular in affected extremities.Encourage passive range motion exercises q 2 h to affec ted extremities and AROM q 2 h to the unaffected Nursing Plans and InterventionsSet realistic goals; add new task daily. To prevent frustration on client that may lead to depression/grief ( loss of function)Teach client that appropriate self-care activities for the hemiparetic client. Instruct client to assist with dressing activities and modify them as necessary. Analyze bladder elimination pattern.Follow-up speech program initiated by the speech and language therapist. Do not place client on sensory overload; give only one set of instructions at a time.Encourage total family involvement in rehabilitation.Encourage client and family to join a support group.

Nursing Plan and InterventionEncourage family members to allow the client to perform self-care activities as outlined by the rehab team This will prevent pt. from total loss of self-esteem. Teach that swallowing modifications may include a soft diet ( pureed foods, thickened liquids) and head positioning.

Nursing InterventionsElevate the affected extremities to promote venous return and to reduce swelling.* Maintain a safe environment to reduce the risk of falls. Client have problem concerning spatial perception. * Instruct the client to us scanning technique (turning head from side to side) when eating and ambulating to compensate for hemianopsia.Provide care to prevent deep-vein thrombosis (sequential stockings, frequent position changes, mobilization.)Administer medications as prescribed.MedicationsSystemic or catheter-directed thrombolytic therapy. Restores cerebral blood flow. It must be administered within hours of the onset of symptoms. It is C/I to treatment of hemorrhagic strokr and for clients with an increased bleeding . Rule out hemorrhagic stoke with MRI prior to initiation of thromboembolytic therapy.Anticoagulants Sodium Heparin, Warfarin (Coumadin).Atiplatelets Aggregates Ticlid (ticlopidine), clopidogrel (Plavix), ASA Antiepileptic medications Dilantin (phenytoin), Gabapentin (Neurontin). Provide assistance with ADL as needed. Prevent complications of immobility.Initiate referrals to social services(rehabilitation services)

Complications and Nursing ImplicationsDysphagia and aspiration. - Suction client as needed. Pre-assess the clients swallowing abilities. - Unilateral Neglect loss of awareness of the side affected by CVA. This process poses great risk for injury and inadequate self-care. Instruc the client to dress the affected side first. Teach the client to care for both sides. * Grief following CVAPoststroke DepressionEtiology: Organic: May be related to catecholamine depletion through lesion-induced damage to the frontal nonadrenergic, dopaminergic and serotonergic projections. Reactive: Grief/psychological responses for physical and personal losses associated with stroke, loss of control that often accompany severe disability, etc. Most prevalent six months to two years. A psychiatric evaluation for DSM-IV criteria and vegetative signs may be a clinically useful diagnostic tool in stroke patients. There may be higher risk for major depression in left frontal lesions (relationship still controversial)Risk factors: prior psychiatric Hx, significant impairment in ADLs, high severity of deficits, female gender, nonfluent aphasia, cognitive impairment, and lack of social supportsPersistent depression correlates with delayed recovery and poorer outcomeTreatment: Active Tx should be considered for all patients with significant clinical depressionPsychosocial interventional program: psychotherapyMedications: SSRIs preferred because of fewer side effects (compared to TCAs); methylphenidate has also been shown to be effective in poststroke depressionSSRIs and TCAs also been shown to be effective in poststroke emotional lability

Seizure DisordersSeizures are abrupt, uncontrolled electrical brain discharges that cause alteration in level of consciousness and changes in motor and sensory behavior.Epilepsy is a group of syndrome characterized by recurring seizures. - it can be idiopathic or secondary caused by conditions such as brain tumor, acute alcohol withdrawal, and electrolyte imbalance. - it is not associated with alterations in intellectual capabilities.* SeizuresAre classified as neurologic emergencies in all triage systems. Sustained untreated seizures can result to hypoxia, cardiac dysrhythmias, and lactic acidosis.

Risk Factors/Contributing Factors - Genetic predisposition - Acute febrile state - Head trauma - Cerebral edema - Abrupt cessation of antiepileptic drugs (AEDs) -Infections - Metabolic Disorder (hypoglycemia) - Exposure to toxins - Brain Tumor - Hypoxia - Acte Drug and alcohol withdrawal - Fluid and electrolyte imbalances.Triggering FactorsIncreased physical activityStressFatigueAlcoholCaffeineSome chemicals

Diagnostics ProceduresElectroencephalogram (EEG) records electrical activity and identifies the origin of seizure activity. Client instructions include: No caffeine Wash hair before the procedure ( no oils or spray) and after the procedure ( to remove electrode glue)Maybe asked to take deep breaths and/or be exposed to flashes of a strobe light during the test.Sleep may be with held prior to test and possibly induced during test.Blood and urine culture test, MRI, CT/CAT, PET scan, CSF analysis, skull x-ray, electrolyte profile and drug screen may all be used to identify or rule out potential causes of seizures.Assessments:Assess and monitor: - Airway patency - Aspiration - Injury post seizure - If client experienced an aura ( warning sensation), possible indication of the origin of seizure. - Possible trigger factor ( e.g. fatigue).

Nursing DiagnosisRisk for injuryRisk for impaired spontaneous ventilationRisk for ineffective tissue perfusion (cerebral).Nursing InterventionsProtect the client from injury ( e.g move furnitures away).Maintain a patent airway.Be prepared to suctionTurn the pt to the side ( decreased the risk for aspiration)Loosen clothing.Do not attempt to restrain the client.Do not attempt to open jaw during seizure activity (may damage the teeth, lips, and tongue). Do not use padded tongue blades.Administer oxygen as prescribed.Administer prescribed medications. ( anticonvulsants and sedatives).Usual medications prescribed : anticonvulsants Keppra, Tegretol, Dilantin, Depakene/Depakote, Phenobarbital sedatives Valium ( Diazepam), Ativan (Lorazepam)Document onset and duration of seizure and client findings/observations prior to during, and following the seizure (level of consciousness), apnea, cyanosis, motor activity, incontinenence).Post Seizure Nursing ManagementMaintain the client in a side-lying position to prevent aspiration and to facilitate drainage of oral secretions.Check Vital signs including O2 saturation level.Perform neurological checks.Reorient and calm the client (maybe agitated).Institute seizure precautions.Provide client education regarding seizure management.The importance of monitoring EAD levels and maintaining therapeutic medication levels.Possible drug interactions (e.g. decreased effectiveness of oral contraceptives.Encourage the client to wear medical alert bracelet (necklace) at all times.

Seizure PrecautionsStandby Oxygen, airway and suctioning equipment.IV access ( medication administration- drug for seizure) Side rails in up position and bed at lowest position.Padded side rails to prevent injury to client.

* Complications and Nursing Implications

Aspiration - Turn the client to side, suction as needed.Status epilepticus potential complication of all seizure disorders. - Establish airway, provide oxygen, ensure IV access, perform EKG monitoring and monitor ABG results. - As prescribed administer Diazepam or Lorazepam and a loading dose following by a continuous infusion of Phenytoin ( Dilantin) * Dilantin can cause gingival hyperplasia, therefore monitor for gingival inflammation and instruct client to use soft bristle toothbrush. Monitor and report gum bleeding if noted.

Considerations and Meeting the needs Older Adults Increased seizure incidence is associated with CVDs.Other prescription medications can interact with seizure control medications as well as food.Absorption, distribution, metabolism, and excretion of medications can be altered changes due to age related to renal and liver functions.Cost associated with antiseizure medications can lead to poor adherence for older adult clients on a fixed income.

Neurosensory DisordersGlaucoma is a disturbance of the functional or structural integrity of the optic nerve. Decreased fluid drainage or increased fluid secretions resulting to increased intraocular pressure (IOP) and can cause atrophic changes and visual defects.Leading cause of blindness. Early diagnosis and treatment is essential in preventing vision loss from Glaucoma.Glaucoma is a chronic disease. It is not curable and its consequences are irreversible. GlaucomaGroup of disorders characterized by increased intraocular pressure (IOP) and the consequences of elevated pressure, optic nerve atrophy, and peripheral visual field loss.

At least 2 million persons have glaucoma;of these; more than 50% are unaware of their condition. Two Primary Types of GlaucomaOpen angle glaucoma - most common form of glaucoma. - Open angle refers to the angle between the iris and sclera; it is normal.Angle closure (close angle) glaucoma - less common form of glaucoma - the angle between the iris and the sclera is decreased.The goal of therapy is to lower the IOP and control the progression of the disease.

Objectives of Nursing Care:Helping the client understand the disease.Helping client to cope with limitations it places on their activities.

Risk FactorsAgeInfectionTumorsDiabetes MillitusGenetic predispositionDiagnostic procedures:Tonometry is used to measure IOP, IOP normal is 10 to 21 mmHg. Elevated with glaucoma, especially angle closure.Gonioscopy determines the drainage angle of the anterior chamber of the eyes.

57PathophysiologyThe etiology of glaucoma is related to the consequences of elevated IOP. Increase IOP results when the rate of aqueous production (inflow) is greater than aqueous reabsorption (outflow).If the pressure remains elevated, permanent visual damage may begin. ClassificationsPrimary Open Angle Glaucoma The aqueous outflow is decreased in the trabecular meshwork. The drainage channels become clogged, like a clogged kitchen sink. Damage to the optic nerve can then result.Primary angle-closure glaucoma the mechanism reducing the outflow of aqueous humor is angle closure. The lens usually bulges forward because of the age related changes, blocking aqueous outflow.Angle closure may also as a result of pupil dilation in the patient with anatomically narrow angles.An acute attack may occur because of drug-induce mydriasis, emotional excitement, or darkness.

ClassificationsSecondary Glaucoma Increased IOP results from other ocular or systemic conditions that may block the outflow channels in some way, such as trauma and ocular tumors.

Nursing Interventions/Diagnostic proceduresLaser Surgery or conventional surgery - both procedures are aimed at improving the flow of the aqueous humor. aqueous humor fluid that is bathing/circulating in the eyes. vitrous humor fluid that is inside the eye that helps in eyes formation. - IOP is checked 1-2 hr. postoperatively by the surgeon. - The post operative eye is covered with patch and protective shield. - The client is instructed not to lie on the operative side and report severe pain or nausea ( possible hemorrage).

Medications Related to Glaucoma Classes of drug are available for use in patients with glaucoma or elevated intraocular pressure.Ophthalmic Beta-Blockers Action: lower pressure in the eye by reducing aqueous production. These drugs are divided into two classes: 1) nonselective beta-blockers (timolol, levobunolol, metipranolol, carteolol); and 2) beta 1 selective (betaxolol). BETOPTIC S (betaxolol HCl) ophthalmic suspension 0.25%.

Non-Selective beta-blocker E.g. Metipranolol Mechanism of Action: Metipranolol has no significant intrinsic sympathomimetic activity, and has only weak local anesthetic (membrane-stabilizing) and myocardial depressant activity. Metipranolol decreases the rate of aqueous production, thereby decreasing intraocularpressure (IOP).

Contraindications/Precautions: AV block greater than first degree, cardiogenic shock, congestive heart failure, diabetes mellitus, hypoglycemia, overt cardiac failure, pheochromocytoma, renal failure, sinus bradycardia, thyrotoxicosis.

Drug Interactions: no significant interactions.

Adverse Reactions: abnormal vision, blepharitis, blurred vision, conjunctivitis, cough, dizziness, edema, excessive lacrimation, eyelid dermatitis, fatigue, ocular irritation and discomfort, photophobia, sinus bradycardia, vertigo.

Adverse reactions from ophthalmic beta-blockers are usually limited to their ocular effects, such as transient burning, stinging, and blurred vision however, these preparations can be absorbed causing systemic adverse reactions, similar to oral or parenteral beta-blockers. Non-Selective beta-blocker TimololBetimol, Blocadren, Timoptic | BETIMOL | BLOCADREN | TIMOPTIC | TIMOPTIC

For the treatment of elevated intraocular pressure in glaucoma or ocularhypertension:

Beta-blocking agents are pharmacological antagonists of sympathomimetics or adrenergic agonists. Administration of timolol with any sympathomimetic or adrenergic agonist could lead to antagonism of some or all of the therapeutic actions of the agents involved. Since timolol is a nonspecific beta-blocker, it should not be used with albuterol, metoproterenol, or other beta2-agonists; or epinephrine, norepinephrine, or other cardiovascular stimulants. NSAIDs can reduce the hypotensive effects of antihypertensives.

Abrupt discontinuation of any beta-adrenergic blocking agent, including timolol, can result in the development of myocardial ischemia, infarction, ventricular arrhythmias, or severe hypertension, particularly in patients with preexisting cardiovascular disease.

Medications Related to Glaucoma Carbonic Anhydrase Inhibitors Action: Also lowers pressure in the eye by decreasing aqueous production. Carbonic anhydrase inhibitors are available as topically (dorzolamide and brinzolamide) or orally (acetazolamide, methazolamide). The topical forms are associated with fewer systemic side-effects than the oral forms and are better tolerated by many patients.e.g. AZOPT (brinzolamide) ophthalmic suspension 1%.

Medications related to Glaucoma Alpha-Agonists Action: Lowers the pressure primarily by reducing the aqueous production. They also may have an effect on increasing the rate at which the fluid drains from the eye. The most frequently prescribed drugs in this class are the relatively selective alpha 2 agonists (apraclonidine, brimonidine) e.g. IOPIDINE 0.5%

Medications Related to Glaucoma Miotics Actions: Miotics decrease IOP by increasing aqueous outflow through the trabecular meshwork. However, because of their ocular adverse effects (increased myopia, eye and brow pain, decreased vision and retinal problems), the use of miotics is declining. Examples of miotics include pilocarpine and carbachol. e.g. ISOPTO CARPINE (pilocarpine HCl) ophtalmic solution, PILOPINE HS (pilocarpine HCl) gel and ISOPTO CARBACHOL (carbachol) ophthalmic solution.

Medications related to Glaucoma Pilocarpine Uses:Treatment of chronic open-angle glaucoma and acute angle-closure glaucoma. Often used as an antidote for scopolamine, atropine, and hyoscyamine poisoning.Also used to reduce the possibility of glare at night from lights if the patient underwent implantation of intraocular lenses; the use of pilocarpine would reduce the size of the pupils, relieving the symptoms. The most common concentration for this use is pilocarpine 1%, the weakest concentration.

Action: Acts on a subtype of muscarinic receptor (M3) found on the iris sphincter muscle, causing the muscle to contract and engage in miosis. Also acts on the ciliary muscle and causes it to contract. When the ciliary muscle contracts, it opens the trabecular meshwork through increased tension on the scleral spur. This action facilitates the rate that aqueous humor leaves the eye to decrease intraocular pressure.

Summary of Medications Medicines that decrease the amount of fluid produced by the eye include:Beta-blockers (such as Betagan, Betimol, Betoptic, Ocupress, OptiPranolol, and Timoptic).Adrenergic agonists (such as Alphagan, Epifrin, Iopidine, and Propine).Carbonic anhydrase inhibitors (such as Azopt, Diamox, Neptazane, and Trusopt).Hyperosmotics (such as Osmitrol, Osmoglyn, and Ureaphil).

Medicines that increase the amount of fluid that drains out of the eye include:Cholinergics (such as Carboptic, Isopto Carpine, Phospholine Iodide, Pilocar, Pilopine HS, and Pilostat).Adrenergic agonists (such as Alphagan, Epifrin, Iopidine, and Propine).Prostaglandin analogs (such as Lumigan, Travatan, and Xalatan).Nursing InterventionsMonitor for s/s of open angle glaucoma - Loss of peripheral vision - Decrease accommodationElevated IOP ( > 21 mmHg)Monitor for s/s of angle closure glaucomaRapid onset of elevated IOP.Decreased or blurred vision.Seeing halos around lightSevere painPhotophobiaAssessment: include a visual assessment and assessment of the ability of the client to cope with changes in vision.

Normal Vision test Snellen Chart. 20 ft on line 20.

Glaucoma- nurse should anticipate a 20/200 vision or less even withcorrection.NANDA Nursing DiagnosisDisturbed sensory perceptionRisk for injuryNursing Interventions:Administer medications as prescribed.Miotics pilocarpine (Isopto carpine) constricts the pupil and allows for better circulation of aqueous humor. Miotics can caused blurred vision.Beta-Blockers timolol (Timoptic) and Carbonic Anhydrase Inhibitors) such as Acetazolamide (Diamox) decrased IOP by reducing aqueous humor production.IV Mannitol emergency treatment for angle closure glaucoma to quickly decrease IOP.Ocular steroid prednisolone acetate (Ocu-pred)NO MYDRISIS meds. Reduced aqueos humor dangerous to client with angle closure glaucoma.Surgery * Trabeculectomy - sometimes also called filtration surgery-a piece of tissue in the drainage angle of the eye is removed, creating an opening. The opening is partially covered with a flap of tissue from the sclera, the white part of the eye, and the conjunctiva, the clear thin covering over the sclera. This new opening allows fluid (aqueous humor) to drain out of the eye, bypassing the clogged drainage channels of the trabecular meshwork. * Trabeculectomy Immediately after surgery, antibiotics may be applied to the eye. After surgery, the eyelid is usually taped shut, and a hard covering (eye shield) is placed over the eye.The client wears a dressing over the eye during the first night after surgery and wears the eye shield at bedtime for up to a month. Corticosteroids are usually applied to the eye for about 1 to 2 months after surgery to decrease inflammation in the eye.People who have a trabeculectomy without being admitted to the hospital usually have a checkup the following day with their eye specialist.

Trabeculectomy cont. Any activity that might jar the eye needs to be avoided after surgery. People usually need to avoid bending, lifting, or straining for several weeks after surgery.After surgery, people who have problems with constipation may need to take laxatives to avoid straining while trying to pass stools. Straining can raise the pressure inside the eye, increasing the risk of damage to the optic nerve or bleeding.Usually there is mild discomfort after a trabeculectomy. Severe pain may be a sign of complications. If client have severe pain after a trabeculectomy, call your doctor immediately.

Trabeculectomy

Trabeculectomy

Complications and Nursing ImplicationsBlindness consequence of undiagnosed and untreated glaucoma.Early Detection encourage adults 40 or older to have an annual examination including measurement of intraocular pressure. Glaucoma is a chronic disease. It is not curable and its consequences are irreversible. Therefore, the nurse should help the client realize the importance of a lifelong compliance with glaucoma medication therapy.

* Cataracts Is defined as opacity of the lens of an eye that impairs vision in one or both eyes.Leading cause of blindness worldwide, major cause of vision loss in the U.S.Cataract surgery is the most common surgery for people 65 years and older.Cataract surgery is 95% successful. Cataract surgery most common surgery in the US

Probable Causes (Etiology)Advanced ageDiabetesHeredityTrauma - Excessive exposure to the sunChronic steroid usePathophysiologyAlthough most cataract are age related (senile cataract), they can be associated with other factors including trauma, maternal rubella, radiation, or ultraviolet light exposure, certain drugs such as corticosteroids, and ocular inflammation.In senile cataract formation, altered metabolic processes within lens cause water accumulation and alteration in the fiber structure of the lens.These changes affect lens transparency, causing vision changes.Etiology and PathophysiologyMost common cataract is due to old age (Senile Cataracts) blunt or penetrating trauma, congenital factors (maternal rubella), radiation or ultraviolet (UV) light exposure, drugs like systemic corticosteroids, and ocular inflammation, the patient with Diabetes Millitus tend to develop cataract at early age.Cataract is mediated by a number of factors, it appears that altered metabolic processes within the lens cause an accumulation of water and alterations in the lens fibers structure that will affect transparency, causing change the vision.Clinical ManifestationDecrease in vision.Abnormal color perception.Glare due to light scattered cause by lens opacities worse at night when the pupils dilates.Secondary glaucoma can occur if the enlarging lens causes intraocular pressure.Diagnostic StudiesBased on decreased acuity or other complaints of visual dysfunction.Direct observation thru opthalmic or slit lamp microscopic examination. Physical Examination.Visual acuity measurement.Glare TestingKeratometryA-scan Ultrasound Visual field perimetry to differentiate visual loss.

Diagnostic Studies Slit Lamp

Slit LampThe slit lamp is an instrument consisting of a high-intensity light source that can be focused to shine a thin sheet of light into the eye. It is used in conjunction with a biomicroscope. The lamp facilitates an examination of the anterior segment, or frontal structures and posterior segment, of the human eye, which includes the eyelid, sclera, conjunctiva, iris, natural crystalline lens, and cornea. The binocular slit-lamp examination provides a stereoscopic magnified view of the eye structures in detail, enabling anatomical diagnoses to be made for a variety of eye conditions. A second, hand-held lens is used to examine the retina.

Non-surgical TherapyNO cure other than surgical removal.Palliative treatment alone may not help. Collaborative Care change prescription of glassess.Strong reading glasses or magnifiers.Increase lighting.Lifestyle adjustment.Reassurance.

Acute Care : Surgical TherapyPreoperative: - Mydriatric cyclopegic p. 413 examples ( Lewis 8th Ed.) ex. Phenylephrine HCl.Nonsteroidal antiinflammatory drugsTopical antibioticsAntianxiety Medications.Surgery Removal of lens.Phacoemulsification. Extracapsular extraction . Scooping.Extracapsular extraction.Correction of surgical aphakiaIntraocular implantation ( most common type of correction. Entire lens is removed with capsule intact.Contact lensPostoperative:Topical Antibiotic.Topical corticosteroid or other antiinflammatory agents. Mild analgesia if necessary.Eye shield and activity as preferred by patients surgeon.Follow Up (at MD office) Check visual acuity, check anterior chamber depth, assess corneal larity, and measure IOP.Therapeutic Procedures/Nursing InterventionsSurgical removal of the lens - Medication such as acetazolamide (Diamox) are administered preoperatively to reduce IOP, to dilate pupils, and to create eye paralysis to prevent lens movement. - a small incision is made and the lens is inserted. Replacement lenses can correct refractive errors, resulting in improved distant vision. - Post operative care should be focused on: preventing infectionAdministering ophthalmic medicationsPain relief.Client teaching for self-care at home. Assessments:Monitor for s/s - Progressive and painless loss of vision -Decreased visual acuity (Prescription changes, reduced night vision) - Glare and light sensitivity. - Blurred vision. - Absent red reflex - Diplopia.Assess/Monitor - Clients history of visual problems - Visual acuity

NANDA NURSING DIAGNOSISRisk for InjuryDisturbed Sensory PerceptionNursing Interventions Post Operative Client EducationWear dark glasses in bright light.Report signs of infection such as yellow or green drainage.Instruct client to avoid activities that increase intraocular pressure (IOP)Bending over waistSneezingCoughingStrainingVomitingHead hyperreflexionRestrictive clothing ( e.g. tight shirt collars)- Sexual Intercourse* Client Instruction Post -OperativelyAdminister postoperative medications as prescribed. - antibiotic steroid eye drops tobramycin combined with dexamethasone. (Tobradex). Instruct the client or the clients caregiver on proper instillation technique. - Analgesics for discomfort.* Limit activities.Tilting head back to wash hair.Only cooking and light housekeeping.No rapid jerky movements ( vacuuming)Avoid driving and operating machinery.Avoid sports. Report pain with nausea and vomiting- indications of increased IOP or hemorrhage.Complications and Nursing Implications Infections In addition to reporting yellow or green drainage, instruct the client to report redness, reduction in visual acuity. Increased tear production, and /or photophobia as these may be signs of infection.

Bleeding a potential risk for several days after surgery. Clients should immediately report any sudden change in visual acuity.Retinal Detachment It is a painless separation of the retina from the epithelium, resulting in the * loss of vision in fields surrounding separation.The onset is abrupt. (Not Chronic) * Retinal detachment is a medical emergency and the assistance of a primary care provider should be sought immediately. Risk Factors NearsightednessFamily HistoryPrevious cataract surgeryEye injuryCausesRetinal tear ( trauma)Fibrous vitreous tissue (pulls retina) Exudate ( form under retina).Therapeutic Procedures and Nursing Interventions The application of freezing probes, laser beams, or high frequency current is used to create a inflammatory response for the purpose of rebinding the retina.Scleral Buckling - Eye rest prior to procedure - It involves general anesthesia for the insertion of silicone and an encircling band to pr0mote attachment and infiltration of gas to push the retina back against the wall of the eye. - An eye patch and shield are applied and the client will lie with affected eye up.- Avoid activities that cause rapid eye movement (reading, writing) for a specified period of time.

Assessments: * Monitor for signs and symptoms - *Bright flashes lights - * Floating dark spots floaters - * Partial: curtain drawing over visual field sensation. - * Loss of visionNANDA Nursing Diagnosis Disturbed sensory perception ( visual) Risk for injury Nursing Interventions Restrict activity to prevent additional detachment.Cover the affected eye with an eye patch.

Nursing Interventions Monitor for eye drainageAdminister medications as prescribed. - Mydriatics ( dilating) preent pupil from constricting and reduce accommodation. - Antiemetics - AnalgesicsInstruct the client to avoid activities that increases IOP such as: bending over at the waist, sneezing, coughing, straining, vomiting, head hyperreflexion, wearing restrictive clothing ( tight shirt collars).

Complications and Nursing Interventions Loss of Vision - the final visual result is not always known for several months post-operatively. More than one atempt at repair maybe required. - The greatest risk for permanent progressive loss of vision is when the detachment is not treated prior to extension to the macula. Therefore, it is important for clients to know and recognize s/s of detachment and to seek professional help immediately. Ear Disorders Sensory Alteration/Hearing Loss Two types of Hearing LossConductive Hearing LossSensorineural hearing Loss

Conductive hearing Loss occurs when sound waves are blocked before reaching the inner ear. Sensorineural hearing loss occurs with cranial nerve VIII and or cochlear damage. Causes of Conductive Hearing Loss Obstruction ( cerumen, foreign objects).Tympanic membrane perforation.Ear infectionsOtoslerosis -progressive degenerative condition of the temporal bone which can result in hearing loss.Causes of Sensorineural Hearing Loss Exposure to loud noises.Ototoxic medications( aminoglycosides) ATBs vancomycin, gentamycin, erythromycin, chemotherapy agents. Aging ( presbycusis - age-related hearing loss, is the cumulative effect of aging on hearing. Defined as a progressive bilateral symmetrical age-related sensorineural hearing loss.Acoustic neuroma benign tumor CNVIII - noncancerous (benign) and usually slow growing. These tumors develop adjacent to your brain on a portion of the eighth cranial nerve, which runs from your brain to your inner ear. Also known as vestibular schwannoma, acoustic neuroma is one of the most common types of brain tumors.Diagnostic Procedures and Nursing InterventionsAudiometry. - an audiogram identifies if hearing loss is sensorineural and/or conductive. Therapeutic Procedures/ Nursing Interventions

Conductive Hearing LossHearing aid lowest setting that allows hearing without feedback noise. Tympanoplasty(ME)/Myringoplasty (eardrum) ear packing, sterile dressing. Position pt. flat with operative ear up for 12 hours. Stapedectomy ear packing, asses the client for facial nerve damage. Intervene for vertigo, nausea and vomiting ( common). Hearing is initially worse.

Sensorineural Cochlear Implant electrodes are placed in the inner ear and a computer is attached to the external ear. Electronic impulses stimulate the nerve fibers.Client teaching following ear surgery :Instruct client to avoid coughing, straining, sneezing with mouth closed, air travel, hair washing, rapid movements, and people with infections.Assessments:Conductive Hearing LossObstructionAbnormal tympanic membrane findingsSoft spokenHears well in a noisy environment AC>BCLateralization to affected ear.Sensorineural hearing LossTinnitusDizzinessLoud SpokenHears poorly in a noisy environmentAC> BCLateralization to unaffected ear.

Asses/Monitor -Hearing Acuity ( whisper test, Weber test, Rinne test)- Tympanic membraane and bone structures ( otoscope) - Functional abilityNANDA Nursing Diagnosis Disturbed Sensory Perception ( auditory)Impaired verbal communicationSocial IsolationImpaired physical mobility Nursing InterventionsCommunicationGet the client attention before speaking.Stand/sit facing the client in a well-light, quiet room w/o distractionsSpeak clearly and slowly.-arrange for communication assistance. ( sign language, interpreter, closed caption, phone amplifiers, TTY capabilities.

Health PromotionNo sharp objects should be placed on ear.Ear protection should be worn for exposure to high intensity noise and/or risk for ear trauma.External ear and canal should be washed dailhy.Nose should be blown gently and with nostrils unoccluded.When wearing head receivers, volume should be kept low as low as possible.Administer meds as prescribed vertigo meclizine hydrochloride ( antivert)Antiemetics ( droperidol ( inapsine)Check for hearing of clients receiving Ototoxic dryugs for more than 5 days. Multiple ATBs., Diretics, NSAIDs, Chemotherapeutic agentsComplications Injury due to vertigoAny questions? Thank you.

The nurse plan to have a right-sided hemiplegia client be repositioned. The help of unlicensed assistive personnel (UAP) is required. Which action by the UAP requires the nurse to intervene? a. The UAP walks the client using a gait belt placed around the clients waist.b. The UAP places a sheet around the client while sitting in the chair.c. The UAP repositioned the client using a lifting sheet up in bed. d. The UAP provided words of encouragement to client when client noted attempting to perform ADLs independently.

The nurse is providing discharge teaching to the client diagnosed with status post cerebrovascular accident (stroke) who has generalized weakness. Which priority intervention should the nurse discuss with the client?a. Request a family member to assist client with all activities of daily living. b. Teach the client to use a long-handled bath sponge for showering.c. Discuss with the client the use of clothes with Velcro closure devices.d. Instruct the client to use a raised toilet seat in the bathroom.

The nurse is caring for clients on a medical-surgical unit. Which client should be attended first by the nurse?

a. The client with pernicious anemia who is complaining of being decreased O2 saturation.b. The client with acquired immune deficiency syndrome who has a platelet count of 45,000.c. The client diagnosed with AIDS who has red raised blotches on the chest.d. The client diagnosed with Cerebrovascular Accident who has right sided paralysis.

The off-duty nurse is walking in the park when an individual called for help. The individual has a splinter embedded into the right eye. Which priority intervention should the nurse implement?

a. Call emergency medical services (911). b. Gently remove the stick from the eye.c. Instruct the client to shut the left eye.d. Stabilize the stick in the clients eye.