Adult Final part 2

• 
  Frontal lobe – speech, motor, Broca’s area
  
• Parietal lobe – sensation, taste, reading
  
• Temporal lobe –hearing, smell, Wernicke’s
  
• Occipital lobe - vision

Right-Brain StrokeAffects the Left Side of the Body

• Trouble knowing how far or near an object is to the body.
• Neglect of left side of the body, or not able to see things to the left of the body.
• Poor decision making, lack of insight into the changes in ability since the stroke, leading to safety concerns .Impulsiveness
• Short attention span and slowed learning of new things. Facial weakness, unclear speech, or problems swallowing.

Left-Brain Stroke Affects the Right Side of the Body

• Trouble speaking or understanding words said or written
• Slow, careful movements.
• Not able to see things on the right side of the body.
• Facial weakness, unclear speech, or problems with swallowing

• Decorticate Posturing(lesion at or above the brain stem)
  Rigidly still
  
• Arms flexed
  
• Fists clenched
  
• Legs extended

• Decerebrate Posturing(lesion below brain stem –intracranial catastrophe)
• 
  Rigid body position
  
• Arms stiff, extended& pronated inward

• Anticonvulsant drugs – lowest dose
  Increase seizure threshold
  
• Limit spread of abnormal activity
  Dilantin w NS, Cerebyx,Tegretol, Gabitrilwith food, Neurontin 2 hrs. after antacids(drugs with many interactions)
  
• Surgery esp. temporal lobe (excise tissue)
  
• Vagal nerve stimulation for partial seizures
  
• Nursing Interventions
  
• Protect
  
• Loosen clothing
  
• Seizure precautions ( Padded side rails)
  
• Education esp. medications

• cushon head
• loosen anything around neck
• turn on side
• do not hold down

• 
  Genetic autosomal dominant disease (50% offspring) yet appears age 30-40
  
• Imbalance of neurotransmitters GABA, acetylcholine & dopamine
  

• S/S: (15-20 yrs. to progress early to late)
  Dementia/psychologic symptoms (irritable, moodswings, depression, then dementia & dependence)
  
• Chorea =Invol. muscle movements/motorsymptoms (fidget, unsteady gait, tongue protrudes, then chorea movements, dysphagia, &unintelligible speech)
  

• TX: no cure (progressive, debilitating)
  
• Anti-psychotics (phenothiazines) block dopamine
  Antidepressants in early stages

• Excitatory influence
  
• Acetylcholine - cholinergic
  
• Norepinephrine (both) – adrenergic
  
• -Alpha – usually excitatory
  
• -Beta 1 & 2 – usually inhibitory
  
• Dopamine (both)
  
• Glutamate
  

• Inhibitory influence
  
• Gamma-aminobutyric Acid (GABA)
  
• Serotonin
  
• Histamine

Unconsciousness= abnorma state when client is not aware of self or environment


Arousal (wakefulness)
Ability to awaken or elicit a response;Reticular Activating System (RAS)


Consciousness
Ability to reason, think, feel, respond to astimulus; Cerebral hemispheres


Due to: Injury to cerebral hemispheres or metabolic disorders

Group of chronic disorders of endocrine pancreas categorized under one broad diagnostic label(DM) with hyperglycemia

• Elevation in level of glucose inblood>126 mg/dL (fasting) X 2
• Normally a certain amount of glucose derived from:
• Gluconeogenesis=build glycogen from ingested fats & proteins
• Glycogenolysis=breakdown glycogen into glucose by the liver via hormone glucagon

• Type 1 Diabetes? (5-10%)
• - Destruction of beta cells leading to an absolute deficiency of insulin. Must be treated with insulin therapy

Type 2 Diabetes? (90-95%)- Disorder with a combination of insulin resistance and a defect ininsulin secretion. May be treated with diet, exercise, oral agents,and/or insulin 40%

Gestational diabetes mellitus (GD Min 2-5% of pregnancies)

• Type I DM
• Juvenile onset-12yrs.
• Insulin dependent
• Autoimmune destruction beta cells
• DKA (ketones)
• Normal or under wt.
• Whites > non whitesesp. Finland
• Abrupt onset s/s
• Tx with insulin

• Type 2
• Adult onset > 40yrs.
• Non-insulindependent
• Resistance to insulin
• HHNK (no ketonesusually)
• Obese
• Native Amer.,Hispanic & Afr. Amer
• Gradual onset s/s
• Tx with diet, exercise& oral agents

• Signs / Symptoms
• diaphoresis
• tremors
• tachycardia
• palpitation
• nervousness
• hunger
• Disorientation
• Unconsciousness
• Seizures
• Glucose < 50mg/dl

• Treatment 15/15 rule
• check blood sugar
• normal blood sugar wait 15 minutes and repeat
• low blood sugar give15 Gm rapid acting carbohydrate and repeat blood sugar in15 min.
• blood sugar remain slow repeat treatment

• Insufficient insulin with fat stores breaking down leading to ketosis & loss of bicarb.
• Metabolic acidosis from ketones
• Hyperosmolarity leads to dehydration & electrolyte imbalance
• Glucose > 250 mg/dL
• pH < 7.3
• Bicarb. < 15 mEq./L
• + Urine ketones & glucose

• Polyuria
• Polydipsia
• Polyphagia
• Kussmauls respirations
• Fruity breath
• Anorexia, nausea,vomiting
• Abdominal pain
• Blurred vision

• damaged nerves and interrupted nerve conduction by the effects of DM caused lack of sensation in the peripheral nerves
• -lack of sensation prevents awareness of injury

• Teaching
• check feet daily- use a mirror
• moisturize dry skin
• cut nail straight across smooth edges with emery board
• never go barefoot-wear slippers when leaving that night
• don't wear open toed shoes
• make sure shoes fit properly
• check shoes for foreign objects
• stockings made of wool or cotton allow perspiration to dry
• don't use heating pad bun feet or icepack
• don't fit with legs crossed that the knees or ankles

Opacity/clouding of crystalline lens due to aging & denaturation of lens protein (bilat.)

• S/S:Cloudy, blurred vision both close & distant
• Poor night vision due to Glare
• Difficult adjusting to light & dark environments
• Unable to distinguish color hues
• Pupils appear cloudy, gray or white rather than black

• DX: dark area instead of red light reflex
• TX: Surgery for intraocular lens implant

• Check visual acuity before & after surgery(stabilizes several wks postop)
• No vomiting, sneezing, coughing, straining, orlifting > 5 lbs. as increases intraocular pressure
• Semi-Fowlers lying on unaffected side to decrease intraocular pressure except retina re-attachment (retinal) surgery
• Sunglasses for photophobia
• Complications (notify MD if):
• Pain or drainage from affected eye
• Hemorrhage/bleeding in anterior chamber
• Flashes of light, floaters, “curtain coming down”
• Cloudy appearance to cornea

Increased intraocular pressure damages retina & optic nerve (leading cause of blindness in U.S.)

• Open angle/chronic simple (90%) with decreased outflow of aqueous humor and increased pressure
• Trabecular network (drainage tubes)becomes clogged with decrease outflow of aqueous humor and increase pressure
• Asymptomatic except painless gradual loss of peripheral vision; bilateral; esp. Blacks

• Closed angle/narrow (10%) with lens shifted forward pushing iris laterally; unilateral; esp. Asians
• Angle for draining at canal of Schlemm is closed not allowing fluid to drain as lens of eye shifted forward pushing iris laterally (esp when dialated)
• Sharp eye pain with colored halo lights
• Abrupt decrease in visual acuity
• Fixed, nonreactive pupils

• Degeneration of Macula resulting in central vision loss; slow & bilateral
• Abnormal accumulation of waste in the retinal epithelium (Drusen)

leading cause of legal blindness and imparied vision in persons over 65

2 Types:Atrophic – dry type (slow progressive);TX. with antioxidant vitamins & visual aids

Exudative – wet type (more aggressive);TX. with laser photocoagulation or photodynamic therapy with verteporfin(avoid sunlight x 5 d) - leaky imature blood vessels form

• Signs & Symptoms
• Loss of central vision
• Blurred vision
• Visual distortion/wavy lines

• Risk Factors –
• Age > 65
• Smoking 2X
• Race: Caucasian
• Lack of antioxidants

• Graying of eyebrows & lashes with coarser hair
• Decrease elasticity of eyelid muscles with crow’sfeet & pseudoptosis
• -Ectropion = lower lid droops away from globe
• -Entropion = lower lid turns inward
• Decrease corneal sensitivity/reflex
• Decrease pupil size & reactivity so less light
• Decrease tearing so dry eyes
• Presbyopia = loss of lens elasticity & near vision
• loss of accommodationdue to aging
• Decrease color perception esp. blue, violet &green
• Decrease depth perception leading to falls
• Senile enophthalmos/recessed eyeballs

blindness is visual acuity no better than 20/200in the better eye with optimal correction. total blindness usually means that the patient has no light perception that all

• interventions
• oriented to the environment verbally and physically
• keep room and hallways free of clutter
• use verbal communications freely
• provide sensory stimuli, such as radio or television
• Orient to food trays using the face of the clock to describe the position of food items on the plate
• when ambulating allow the patient to hold your arm. As you walk, slightly ahead - verbally describe the environment
• asked what assistance. The patient desires

Hypertension can cause damage to the blood vessels in the retina, the area at the back of the eye where images focus.

• S & S
• Headache
• Vision problems

• Dx:
• Narrowing of blood vessels.
• Fluid oozing from the blood vessels.
• Spots on the retina known as cotton wool spots and exudates.
• Swelling of the macula (the central area of the retina) and optic nerve.
• Bleeding in the back of the eye.

• Tx and prevention:
• annual ophthalmolic exam
• To prevent hypertensive retinopathy, keep your blood pressure in control by changing your diet, exercising more, and taking your high blood pressure medications as prescribed.

strict control of blood glucose levels and blood pressure are important preventative measures, and may slow the progression of retinopathy

• = infection of middle ear
• Serous Otitis Media
• Pain esp. change in barometric pressure (diving or airplane)
• Popping or snapping in ear
• Bulging tympanic membrane
• Vertigo

• Suppurative/Acute Otitis Media
• Ear Pain/otalgia
• Tinnitus
• Fever
• Purulent discharge
• Vertigo
• Conductive hearing loss
• Bulging, red tympanic membrane
• Chronic Otitis Media

• Children at higher risk
• Short, straight eustachian tube
• Age esp. 6 – 12 mos. or < 2 yrs.

• = over accumulation of ear endolymph
• recurring attacks of vertigo, gradual loss of hearing, and tinnitus

• S/S: Episodic, incapacitating vertigo
• Tinnitus (fullness or roaring)
• Gradual sensorineural hearing loss(usually unilateral)
• Fullness/pressure sensation in ear
• Ataxia/falling toward the affected side
• Hypotension, sweating & nystagmus

• TX: Anti-vertigo/anti-emetics
• Labyrinthectomy
• Endolymphatic decompression & shunt to subarachnoid space
• Low salt diet without coffee, ETOH, or tobacco & with diuretics
• Vestibular neurectomy sever CN#8

• Diuretics (Lasix)
• Chemotherapeutic agents (Cisplatin) - platimun based
• Antimalarials (Quinine)
• Anti-inflammatory agents (ASA)
• Chemicals (nicotine, ETOH, caffeine)
• Antibiotics (aminoglycosides)
• Metals (gold, mercury, lead)

• S & S
• Hearing loss
• tinnitus
• dizziniess (vertigo)

• Conductive loss involves middle & external ear due to mechanical cause (incus, malleus, and stapes)
• Cerumen impaction
• Unable to hear “muffled” tones, all freq.
• Rinne test bone>air conduction
• Weber test lateralizes sound to deaf ear
• Hearing aid helpful

• Sensorineural loss due to structural changes to inner ear (cochlea) or auditory nerve
• Presbycusis/hearing loss high pitched tones
• Difficulty filtering out background noise
• Rinne test air>bone conduction but < 2:1
• Weber test lateralizes sound to unaffected ear
• Hearing aid doesn’t help as increase background

• otoscope
• tympanic membrane is pearly gray, shiny, and semi transparent. The surface should be continuous, intact, and either flat or concave

• Weber test
• normally heard equally in both years
• conductive hearing loss-sound is louder on the impaired side
• sensorineural hearing loss-sound is softer on impaired side

• Rinne test - fork on mastoid bone & next to ear
• air conduction> bone conduction 2:1

• Conductive hearing loss
• bone conduction> air conduction

• gradual hearing loss associated with aging
• higher pitched tones and conversational speech are lost. Initially

hearing aids and amplification devices are useful