Dementia and Alzheimer’s Disease

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Dementia andAlzheimers Disease
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Dementia

• Loss of
• Memory
• Orientation
• Language
• Judgment
• Reasoning

• Personality and behavioral problems
• Agitation
• Delusions
• Hallucinations

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Dementia

• Neurodegenerative conditions
• Alzheimers Disease
• Parkinsons
• Huntingtons
• Vascular dementia, multiinfarct dementia
• Emboli
• CVA

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Clinical Manifestations

• Mild
• Forgetfulness
• Decreased judgment
• Geographic disorientation
• Moderate
• Loss of remote memory
• Forgets how to do simple tasks
• Severe
• Unable to perform ADLs
• Difficulty eating, swallowing
• Immobility and incontinence

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Alzheimers disease

• Chronic, progressive, irreversible
• 60 - 80 of dementias
• Etiology unknown
• Memory loss usually first sign
• Structural - Neuritic plaques
• Decrease in neurotransmitters

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Pathophysiology of AD

• Amyloid plaques
• Neurofibrillary tangles
• Loss of connections between cells and cell death

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Diagnosis of AD

• Three stages
• Sundowners
• Mini mental exam

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Pharmacology

• Decreased memory and cognition
• Aricept, Exelon, Razadyne, Namenda
• Depression
• SSRIs, tricyclic antidepressnats
• Behavioral problems
• Antipsychotics, neuroleptics, benzodiazepines
• Sleep disturbance
• Ambien

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Caregiver Role Strain

• Majority cared for by family members
• Overwhelming - 24/7 task
• Need support of family
• Need education and assistance from nurse

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Delerium

• Temporary but acute mental confusion
• 15 to 53 of post-op older adults
• 70 to 87 of older adults in ICU
• Medications
• Anesthesia
• Major surgery
• Infection
• Sleep deprivation

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Delerium

• Early signs

• Later signs

• Inability to concentrate
• Iritability
• Insomnia
• Loss of appetite
• Restlessness
• Confusion

• Agitation
• Misperception
• Misinterpretation
• Hallucinations

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Delerium The Nurses Role

• Recognition of high-risk patients
• Eliminate precipitating factors
• Protect from harm

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Creutzfeldt-Jacob Disease

• Progressive causes brain degeneration without
  inflammation
• Can be fatal
• Form of dementia is caused by a pathogen called a
  Prion
• Believed to be from livestock Mad Cow Disease

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Creutzfeldt-Jacob Disease
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Effects of Nerve Agents
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Types of Chemical Nerve Agents

• Organophosphates
• Insecticides are easily obtained and commonly
  used in the community
• Like insecticides
• Parathion
• Malathion
• Diazinon
• Chlorpyrifos

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Nerves the "perfect" target

• Soon after the first organophosphate compound was
  invented at the German firm IG Farben in 1934,
  many recognized that it could be used as a
  pesticide -- or a chemical weapon.
• Organophosphates kill insects and people by
  jamming the nervous system.
• By the end of the 1930s, German chemists had
  produced about 2,000 organophosphates, including
  sarin. Military planners assumed these weapons
  would be used by the brink of World War II,
  Britain had stockpiled 30 million gas masks.

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How nerve agents work

• Acetylcholine is a common neurotransmitter found
  in the central and peripheral nervous system.
  When acetylcholine is released from an axon
  terminal, it moves across the synaptic cleft to
  bind to a receptor on the other side of the
  synapse (on the post-synaptic membrane). In the
  peripheral nervous system, acetylcholine is
  located at the "neuromuscular junction" where it
  acts to control muscular contraction..

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• Acetylcholine is also used in the autonomic
  nervous system. The action of acetylcholine is
  stopped by an enzyme called "acetylcholinesterase"
  (AChE). Nerve agents bind to part of the AChE
  molecule. This makes the AChE inactive and blocks
  the action of AChE. Therefore,
• there is no way to stop the action of
  acetylcholine
• acetylcholine builds up at the synapse.
• acetylcholine continues to act

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• That causes the typical effects of nerve gas
  violent tremors, incontinence, even heart and
  lung failure. "Exposure to a higher dose of
  nerve weapons leads to bronchioconstriction and
  secretion of mucous in the respiratory system
  leads to difficulty in breathing and to coughing.
  Discomfort in the gastrointestinal tract may
  develop into cramp and vomiting. Involuntary
  discharge of urine and defecation may also form
  part of the picture. The discharge of saliva is
  powerful and the victim may experience running
  eyes and sweating.

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• "When exposed to a high dose of nerve agent, the
  victim may suffer convulsions and lose
  consciousness. To some extent, the poisoning
  process may be so rapid that earlier mentioned
  symptoms may never have time to develop.
• "Muscular paralysis caused by nerve agents also
  affects the respiratory muscles. Nerve agents
  also affect the respiratory center of the central
  nervous system. ...Consequently, death caused by
  nerve agents is a kind of death by suffocation."

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Nerve Agents

• Tabun, Sarin, Soman
• Most toxic of the chemical agents
• Penetrate skin, eyes, lungs
• Loss of consciousness, seizures, apnea, death
  after large amount

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EFFECTS OF NERVE AGENTS

• Hyperstimulation of organs of cholinergic
• nervous system
• Muscarinic
• Smooth muscles
• Glands
• Nicotinic
• Skeletal muscles
• Ganglions

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Nerve Agent Treatment

• Airway/ventilation
• Antidotes
• Atropine - Antagonizes muscarinic effects
• Dries secretions relaxes smooth muscles
• Given IV, IM, ET
• No effect on skeletal muscles
• 2-PAMCl
• Diazepam
• Decreases seizure activity
• Reduces seizure-induced brain injury

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Peripheral Nerveand Spinal CordProblems
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Trigeminal Neuralgia

• AKA tic douloureux
• Facial pain
• Etiology unknown
• Pharmacology
• Tegretol
• Surgery

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Bells Palsy

• Sudden onset involving one side of face
• Facial paralysis, drooping
• 80 recover completely within few weeks to few
  months
• Steroids?

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Guillian-Barre

• Rapid muscle weakness and paralysis
• Post viral in etiology? Epstein Barr virus
• Ascending paralysis of the limbs

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Guillian-Barre

• Testing
• CSF Increased protein levels
• EMGDecreased response
• Rx Plasmaphoresis

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Tetanus

• AKA Lockjaw
• Anerobic microorganism found in dirt
• Incubation 8 to 12 days
• Pain at site of infection
• Pharmacology
• Human tetanus
• immune globulin
• PCN
• Thorazine
• Valium

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Botulism

• Food poisoning
• Incubation 12 to 36 hours after ingestion
• Symptoms
• Blurred vision
• n/v
• Paralysis

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Spinal Cord Disorders
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Spinal Cord Disorders--Types

• Spinal Cord Injury
• Herniated Intravertebral Disks
• Spinal Cord Tumors

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Spinal Cord Injury

• Usually due to trauma
• Deformation - abnormal movements
• Penetrating injuries
• Classifications of injuries
• Complete/Incomplete
• Cause of injury
• Level of injury

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Upper and Lower Motor Neuron Deficits

• Upper
• Voluntary movement
• May have spastic paralysis
• Hyperreflexia
• Lower
• Both voluntary and involuntary movement
• Muscle flaccidity
• Muscle atrophy

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Spinal Shock

• Temporary loss of reflex function below level of
  injury
• Immediate response to spinal cord injury
• Manifestations
• Bradycardia
• Hypotension
• Flaccid paralysis
• Loss of sensation

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Autonomic Dysreflexia

• Exaggerated sympathetic response
• Caused by a stimuli i.e. over distended bladder
• Symptoms
• Bradycardia or tachycardia
• Hypertension
• Flushing
• Diaphoresis, pallor, coolness

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Emergency Care of Potential Spinal Cord Injury

• ABCs
• Immobilize neck
• Monitor Neuro status--Baseline
• Monitor VS
• Cardiac monitor
• Diagnostics
• Pharmacology
• Cervical traction/Halo fixator

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Spinal Cord Tumors

• Benign/malignant
• Primary/metastatic
• Symptoms depend on location, level of tumor, size
  of tumor, type of tumor, and spinal nerves
  involved
• Tx Surgery/Radiation

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Herniated Intervertebral Disk/Back Pain

• Cervical vertebrae and lumbosacral most commonly
  affected
• Kyphoplasty

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Kyphoplasty
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Cervical Back Pain

• Can result from herniated nucleus propulsus (HNP)
  in an intervertebral disc
• May also occur from muscle sprain or ligament
  sprain

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Lumbosacral Back Pain

• Also known as low back pain
• More common than cervical pain
• Acute pain - muscle strain or spasm, ligament
  sprain, disc injury
• Young - usually due to trauma
• Elderly - can be from DJD

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Herniated Disk - HNP
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Assessment of Back Pain

• Posture and gait
• Vertebral alignment
• Sensation
• Muscle tone

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Diagnostic Testing

• X-rays
• MRI
• CT
• EMG
• Myelography

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Pharmacology

• Muscle relaxants - Flexeril
• NSAIDs
• Opioids - avoid if possible
• Steroid injections

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Operative Procedures

• Diskectomy
• Laminectomy
• Spinal fusion

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Fusion with Plates and Screws
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Post Op Care

• Fusion - brace
• May have to log roll patient

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Iron Lungs Circa 1945
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Postpolio Syndrome

• Complication of previously affected by
  poliomyelitis virus
• Fatigue, muscle weakness, respiratory difficulties

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Water Therapy
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Nursing Care of Clients with Visual Problems
Susan Wise, RNC, PhD
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Review of the Structure and Function of the
Visual System

• Please review this system in your current nursing
  or anatomy and physiology book

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Brief Review of the Eye

• Eyeball covered with three layers
• Outer layer is the sclera
• Middle layer is the choroid
• Inner layer is the retina

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VISION

• Is the reflection of light from an object,
  through the cornea, aqueous humor, lens, and
  vitreous humor to the retina, where it is sent to
  the cerebral cortex and perceived as an image.

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Structures of the Eye
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Assessment/History

• Change in vision?
• Contact lens? Protective eyewear?
• Family history of eye problems?
• Problems reading? Pain? Itching?
• Night Driving?
• Current diseases/family history/
• Medications

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Assessment of the Eye

• Visual Acuity
• Snellen Chart

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Assessment of the Eye

• Visual fields
• Extraocular muscles
• Pupil function
• Intraocular pressure

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Assessment of the Eye

• IOP by Tonometry
• Opthalmoscopy

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Healthy Retina?
or
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Assessment of External Structures

• Eyebrows, lashes and lids
• Tear ducts
• Conjunctiva
• Sclera
• Cornea
• Irises

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Visual Defects

• Myopia
• Hyperopia
• Astigmatism
• Presbyopia

(National Eye Institute, NIH)
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Visual Defects

• Aphakia
• Corrections include glasses, contact lenses, and
  surgical intervention such as LASIK.
• Intraocular lens implant used for aphakia

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Uncorrectable Visual Impairment

• Severe impairment
• Functional blindness
• Legal blindness
• Total blindness

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Nursing Diagnoses for Clients with Visual
Impairment

• Sensory-perceptual alterations
• Risk for injury
• Self-care deficits
• Fear
• Social isolation
• Knowledge deficit

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Extraocular Disorders

• Infection Inflammation of lids
• Hordeolum (sty)
• Chalazion
• Blepharitis

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Extraocular Disorders

• Conjunctiva
• Conjunctivitis

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Extraocular Disorders

• Cornea
• Keratitis

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Nursing Diagnoses

• Pain
• Anxiety
• Sensory-perceptual alteration

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Cataracts
(National Eye Institute, NIH)
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Cataracts

• Opacification of Lens
• Etiology
• Symptoms
• Treatment

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Post-op Eye Surgery Care

• Nursing Interventions and Teaching are Aimed At
• Preventing Increased IOP
• Preventing Infection
• Preventing Injury

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Glaucoma
(National Eye Institute, NIH)
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Glaucoma

• Signs and Symptoms
• Primary open-angle glaucoma
• Primary angle-closure glaucoma
• Acute angle-closure glaucoma

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Glaucoma Treatment

• Beta Blockers Timoptic, Betoptic
• Cholinergic Pilocarpine,
• Adrenergic agonists Epinephrine, Alphagan
• Carbonic Anhydrase Inh. Diamox
• Laser Iridectomy
• Trabeculectomy

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Age Related Macular Degeneration
(National Eye Institute, NIH)
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Eye 911

• Retinal Detachment
• Ocular Trauma
• Infection
• Acute Glaucoma

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Systemic Disorders That Effect the Eye

• Diabetes
• Hypertension
• Graves Disease
• Infections CMV, TB
• Vitamin deficiencies
• Immunosuppression-AIDS, Herpes

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Preventative Care

• Vision Screenings
• Glaucoma Screening
• Protect Your Eyes

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Ears

• RNs Role in Assessment
• Prevention of Problems

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Signs of Hearing Difficulty

• Irritable, Hostile, Withdrawn
• C/O People Mumbling
• Doesnt Get Jokes
• TV on Loud
• Asks for words to be repeated
• Answers questions inappropriately
• Smiles instead of responding to your question

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Hearing Assessment
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Hearing Assessment
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Assessment - History

• Change in hearing?
• Balance
• Tinnitus
• Pain
• Effect on job, hobby or relationship
• Medications

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Assessment

• External Ear
• Otoscopic Exam

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Tympanic Membrane
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Diagnostic Studies

• Whisper test/Ticking watch test
• Tuning-Fork tests
• Audiometry
• Vestibular function tests

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Ear Disorders

• External Ear and Canal
• Trauma
• External Otitis
• Cerumen foreign bodies
• Malignancy

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Ear Disorders

• Middle Ear and Mastoid
• Otitis Media, acute
• Otitis Media, chronic and Mastoiditis
• Otosclerosis

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Ear Disorders

• Inner Ear Menieres
• Hearing Loss
• Presbycusis
• Conductive/Sensor neural

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Ear surgery Post-op Care

• Pain
• High Risk for Injury
• High Risk for Infection
• knowledge Deficit

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Ear Care

• Nothing Smaller Than Your Elbow
• If It Sounds Too Loud--It Probably Is!

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Ototoxic Medications

• Mycin drugs(Vancomycin, Erythromycin,
  Gentamycin, etc.)
• Salicylates
• Loop Diuretics, Diamox
• Quinine, Quinidine

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Hearing Aid Care

• Turn Off When Not in Use
• Keep Extra Batteries
• Keep Clean
• DO NOT Get Wet
• DO NOT Wear During an Infection