- Medical–Surgical Nursing: NEUROLOGICAL DISORDERS
- FURTHER READING/STUDY:
- EKG: Acute Myocardial Infarction Patterns
- NCLEX: SKIN DISORDERS
- NCLEX: Immunologic disorders
- NCLEX: Hematologic and lymphatic disorders
- NCLEX: Reproductive system disorders
- NCLEX: Musculoskeletal disorders
- NCLEX: End-of-life care
- NCLEX: Gerontologic care
Medical–Surgical Nursing: Artificial Airways/Chest Tubes/Ventilators
Focus on this section of Medical–Surgical Nursing in detail. I will describe the most frequently tested and important information. Use this section as study aid to your textbook and class notes. You will be required to know the different artificial airways and nursing care for all. Just a little heads-up: The information in this section was often included on tests.
Definition: Placement of an endotracheal tube through the mouth or nose into the trachea to maintain a patent airway. This is used in emergencies on patients with respiratory distress or respiratory failure. Oral intubation is the first choice in a critical situation because of the size of the tube and the rapid opening of the airway. Nasal intubation would be the second choice if oral intubation was not accessible. Remember, never use nasal intubation for a patient who has a facial injury or one in whom the oral airway is obstructed.
Intubation Procedure/Nursing Care: A physician performs the insertion of the endotracheal tube with the assistance of the nurse. Prepare all equipment for the insertion. Sedate the patient and apply soft restraints to keep the patient from pulling out the tube. Keep the head of the bed flat and suction equipment nearby. A crash cart may be needed at the bedside. As the tube is being inserted, the nurse’s role is to provide oxygen to the patient using an Ambu bag. The patient receives 100% of oxygen for 3 to 5 minutes. After insertion, the cuff is inflated while on the ventilator. Assess for chest symmetry and breath sounds every 2 hours. ABGs are evaluated every 20 to 30 minutes. At the end of the procedure, a chest x-ray is done to ensure proper placement of the tube. Intubated patients are closely monitored in the ICU.
Definition: This is a surgical opening of the trachea to maintain an open airway. Tracheostomy can be used for long-term or short-term airway assistance. A fenestrated tracheostomy is used with a ventilator and without. The nursing role in caring for a patient with a tracheostomy is to remove secretions, provide trach care, and maintain the airway.
Nursing Care: Using sterile technique, it is important to clean the tracheostomy site. The tracheotomy tube is secured with ties. When cleaning the trach, apply new ties before removing the old ones. Removing the ties before can cause the trach to move, causing a loss of airway patency or distress. If the tracheostomy tube is accidentally removed, hold the stoma open with a hemostat until the physician arrives to place a new tube. Always maintain a patent airway and monitor oxygen levels.
Suctioning an Artificial Airway: Patients with artificial airways tend to build up secretions that they are unable to cough up on their own; these must be suctioned to clear the airway. First, auscultate lung sounds and monitor O2 levels. Suctioning must be done in a sterile field and performed effectively to avoid complications. Explain the procedure to the patient and what to expect. If the patient has a stoma, at times the patient can self-suction.
Refer to your textbook for the exact procedure used to suction the artificial airway, and look at the images provided to gain a better understanding. When suctioning, the suction device should be turned on for only about 10 to 15 seconds; do not suction longer than this as doing so can compromise the patient’s airway and cause a change in heart rate. Complications of suctioning are hypoxia, respiratory distress, and damage to the airway.
To be honest, I was not tested much on ventilators. The three most common types are explained below.
Positive end-expiratory pressure (PEEP): It is used to maintain pressure in the alveoli of the lungs during exhalation. Ventilator settings are ordered by the physician. PEEP can cause a decrease in blood pressure.
Continuous positive airway pressure (CPAP): It is used for patients who are able to breathe spontaneously and provides a continuous flow of air. These patients do not require the ICU; CPAP can be used at the bedside or provided through the nasal cannula. CPAP is commonly used for patients with sleep apnea.
Bilevel positive airway pressure (BiPAP): This is a noninvasive type of ventilation used via face mask to deliver airflow; it differs from CPAP in that it can deliver periodic airflow instead of the continuous flow provided with CPAP.
Now you can take a deep breath! We are all finished with respiratory disorders. Hope all this information isn’t causing you to experience respiratory distress.
Medical–Surgical Nursing: NEUROLOGICAL DISORDERS
Assessing a Patient With Neurological Disorders
Review the anatomy and physiology of the central nervous system in your textbook. Obtain a health history from the patient. Assess any new symptoms as well as chronic neurological disorders the patient may have. Remember that when assessing the patient’s mental status and performing the exam, culture, language, and age will affect the exam. The Glasgow Coma Scale is used to assess the neurological status of a patient:
- Eyes open: Check whether the patient can open eyes on command, and whether pupils are equal, round, and react to light.
- Verbal response: Check the patient’s ability to state self, place, and year, and to answer questions appropriately. This part of the exam is used to assess pain, as well.
- Motor response: Check the patient’s ability to follow commands. Also check flexion and strength of the upper and lower extremities.
An interpreter may be used to conduct this exam if the patient does not speak English. Keep in mind that older patients with an underlying problem such as dementia or Alzheimer’s disease may score poorly on the scale. Neurological assessments are done on all patients. If there are any acute changes, call the physician immediately. Stroke is a common neurological emergency and must be treated immediately. We will go over the signs and symptoms of a stroke.
Magnetic Resonance Imaging (MRI): This test uses radio waves to produce images of the body. It is able to show tumors, blood vessels, and masses, and can be done with or without contrast.
Computerized Axial Tomography (CAT scan): This test uses x-ray images to dissect sections of the brain. It is able to show hemorrhage, tumors, edema, or fluid in the brain.
Electroencephalography (EEG): This test is used to measure activity in the brain by means of electrodes applied to the head. It is also used to diagnose seizures.
Lumbar Puncture: Spinal fluid is extracted from the spine at the level of L4 to L5 using a needle to aspirate the fluid. Lumbar puncture is used to diagnose meningitis or to determine if there is glucose in the spinal fluid.
Cerebral Angiogram: Cerebral blood flow is viewed by injecting dye through a catheter and gently inserting the catheter into the femoral artery to view blood flow.
Medical–Surgical Nursing: Stroke
Definition: A disruption of blood flow causing interruptions in the neurological system and brain function. Also known as a cerebrovascular accident, a stroke can be caused by a hemorrhage, clot, or ischemic attack. Transient ischemic attacks (TIAs) present differently than a complete stroke.
Signs and Symptoms of TIA: Blurred vision, unsteady gait, numbness or tingling of an extremity, and slurred speech can occur. These symptoms and signs can last for several days. An MRI is used to determine if the patient is experiencing a TIA.
Signs and Symptoms of a Hemorrhagic or an Embolic Stroke: A right-sided brain injury affects the left side of the body, and a left-sided brain injury affects the right side of the body. A right-sided brain injury presents with left-sided weakness or paralysis, drooping of the face, headache, slurred speech, sensory changes, and difficulty with short-term memory or communication. A left-sided brain injury presents with right-sided weakness, right-sided face drooping, visual changes, depression, aphasia, and difficulty communicating.
Patients who experience a subarachnoid hemorrhage have distinctive symptoms, which they describe as the “worst headache of their life.”
Diagnostics: MRI or CT scan of the brain. Labs such as PT, PTT, INR.
Complications: Permanent paralysis, weakness, seizure, and death if left untreated.
Drug Therapy: Thrombolytic or fibrinolytic therapy (tissue plasminogen activator) can be used for nonhemorrhagic strokes within 3 to 4.5 hours of a stroke. Do not give patients with a subarachnoid hemorrhage fibrinolytic therapy. Diagnostics are used to determine the type of stroke. Once a stroke is diagnosed, a “stroke alert” is made. Anticoagulants are prescribed for thrombic strokes. Osmotic diuretics are used to relieve pressure in the brain. Anticoagulants, aspirin, antiepileptics, and IV fluids are commonly used to treat strokes.
Surgical Measures: Angioplasty (stent placed in the carotid artery), carotid endarterectomy (removal of plaque in the carotid arteries), and craniotomy if needed.
Nursing Care: Maintain a patent airway, and make sure the patient is not in respiratory distress. Assess airway, breathing, mental status, and vital signs. Prevention of strokes is key. The nurse’s role is to first be aware of a stroke, assess signs of increased cranial pressure, identify the type of stroke, and administer medications as quickly as possible. Patients are kept in the ICU during the acute stages. A Foley catheter may be placed for adequate output records, and patients may be incontinent during the acute stages of the stroke. For patients who suffer from dysphagia, aspiration precautions need to be in place. Swallow and gag reflex needs to be assessed before patients can start eating. Thickened liquids and pureed foods may be needed. Patients may also experience weakness and paralysis on one side of their body, so it is important to maintain safety for these patients. Physical therapy and occupational therapy may be ordered to help regain strength and movement. Provide emotional support, because this period is difficult for both patients and families to cope with. Continue to conduct neuro checks every 2 to 4 hours, check vital signs every hour, and check respiratory status frequently. Be sure to report any changes or critical findings to the physician immediately.[sociallocker]
Medical–Surgical Nursing: Seizures and Epilepsy
Definition: A disruption of neurons in the brain that can be caused by trauma to the brain, tumors, infections, substance withdrawal, and/or other etiology.
Types: There are two main types of seizures: partial and generalized. Partial seizures are subdivided into two types, namely, simple partial and complex partial. The second type, generalized seizures, can be tonic-clonic, absence, or myoclonic.
Signs and Symptoms:
Simple Partial Seizures: These occur in one specific area and produce a tingling sensation in the area. Other symptoms include jerking in the area, increased heart rate, and abdominal discomfort.
Complex Partial Seizures: Loss of consciousness, jerking of the extremities, confusion, involuntary movement of lips, and inability to speak during a seizure.
Tonic-Clonic Seizures: Loss of consciousness for 2 to 5 minutes, rapid and violent jerking movements, tongue biting, shortness of breath, cyanosis, and disruption of breathing may occur.
An aura may appear before seizure activity in some cases.
Diagnostics: Electroencephalography (EEG) to see the electrical activity in the brain, CT brain, and MRI of the brain.
Complications: Status epilepticus, which is continuous seizure activity that can cause airway obstruction and brain damage. This is a medical emergency, and maintaining an open airway is a priority.
Drug Therapy: Antiepileptics such as phenobarbital (Sodium Luminal), phenytoin (Dilantin), valproic acid (Depakote), and levetiracetam (Keppra) are commonly used to treat seizures. Levels of the medication are often checked through lab work to maintain a healthy level of medication in the body. Oxygen therapy may be needed during and after a seizure.
Nursing Care: Patients who present with seizure activity must be placed on seizure precautions and closely monitored. Side rails of the beds must be padded. Patients must be given assistance when walking. Keep emergency airway equipment at the bedside. Maintain a patent airway if patient is having a seizure (Ambu bag, suction, and O2 must be at bedside). Never force anything in the mouth or down the throat during a seizure. As a nurse, you must document seizure activity, if possible (duration, description of movements, and any triggers). Administer medications as ordered. Maintain hydration and nutrition. Most seizures are 1 to 5 minutes in duration.
Medical–Surgical Nursing: Parkinson’s Disease
Definition: This is a progressive disease caused by decreasing amounts of circulating dopamine (a primary neurotransmitter responsible for motor movement) due to progressive damage to the nerve cells. An insidious weakening of the muscles is a common occurrence with Parkinson’s.
Signs and Symptoms: Muscle rigidity, tremors, dysphagia, difficulty swallowing, urinary retention, decrease in facial expressions, depression, bradykinesia, drooling, and a shuffling gait.
Diagnostics: Lab work such as monitoring dopamine and acetylcholine levels. There are no definitive tests for Parkinson’s.
Complications: Progression and worsening of the symptoms.
Drug Therapy: Anti-parkinsonian medications are used to help balance dopamine and acetylcholine levels. Dopaminergics such as carbidopa/levodopa (Sinemet) and amantadine (Symmetrel) are commonly used. An anticholinergic such as benztropine mesylate (Cogentin) is commonly used.
Nursing Care: Promote and teach the patient the importance of maintaining a safe environment in view of an increased risk of falls. Offer assistive devices such as a cane or walker. Decrease clutter in the room. Assist with daily activities. Assess the patient’s ability to swallow, and increase calorie intake. If the patient is having difficulty swallowing, a soft diet or pureed diet may be ordered. Physical therapy is ordered to maintain muscle strength and range of motion. Educate and provide emotional support to both to patients and their families.
Medical–Surgical Nursing: Multiple Sclerosis
Definition: Multiple sclerosis (MS) is an autoimmune and progressive disease caused by the destruction of the myelin tissue in the brain. The destruction of the myelin tissue leads to a progressive loss of function.
Signs and Symptoms: Generalized weakness, muscle pain, tremors, dizziness, numbness, fatigue, diplopia (double vision), decreased concentration, disruption in speech, confusion, muscle spasms, abnormal reflexes, loss of sensory function, urinary retention, and incontinence.
Diagnostics: There are no definitive tests for MS. MRI of the brain or testing of the cerebrospinal fluid may be assessed.
Complications: Progression and worsening of symptoms. If left untreated complete loss of muscle function may occur.
Drug Therapy: Corticosteroids such as prednisone or IV methylprednisolone (SoluMedrol) are used to treat attacks. Plasmapheresis may be used if corticosteroids are ineffective. Beta-interferons such as Avonex, Betaseron, and Rebif are commonly used. To decrease muscle spasms, muscle relaxers such as baclofen (Lioresal) or diazepam (Valium) are used. Antidepressants may be administered. Pain medications are also used.
Nursing Care: Provide periods of rest to decrease fatigue. Fall precautions may be needed when patients are experiencing periods of weakness. Assistive devices may be needed. Monitor bowel and urinary function, and monitor for urinary retention. In view of the loss of sensory function, teach patients to avoid extreme temperatures. Patients who are on long-term steroids may have thin and fragile skin; hence, use precaution to prevent skin tears. Adequate nutrition and hydration are needed.
Medical–Surgical Nursing: Amyotrophic Lateral Sclerosis
Definition: Also known as Lou Gehrig’s disease, amyotrophic lateral sclerosis (ALS) causes progressive damage to the nerves that eventually impairs involuntary muscle movements. (The famous “Ice Bucket Challenge” was created to raise money for ALS.)
Signs and Symptoms: Muscle cramping, muscle weakness, twitching, fatigue, and, eventually, loss of all motor function.
Diagnostics: Electromyography and muscle biopsy.
Complications: Complete muscle loss and death.
Drug Therapy: Corticosteroids and riluzole (Rilutek).
Nursing Care: Maintain safety in view of the risk of falls. Assist with daily activities. Assistive devices may be used. Advise patients to conserve energy and ensure periods of rest. Monitor hydration and nutrition. Assist with eating or drinking by placing patients at a 90 degree angle to prevent aspiration. Family and patient teaching is needed, along with emotional support.[/sociallocker]