Med Surg Exam #3 Study Guide
Med Surg Exam #3 Study Guide
Alzheimer’s disease and the management; nursing care of the patient with Alzheimer’s
What is it: AD is a progressive, irreversible degenerative neurologic disease that begins ...
Med Surg Exam #3 Study Guide
Alzheimer’s disease and the management; nursing care of the patient with
Alzheimer’s
What is it: AD is a progressive, irreversible degenerative neurologic disease
that begins insidiously and is characterized by gradual loss of cognitive
function and disturbances in behavior and affect. Aka senile dementia – most
common form of dementia.
Uncommon before 65 – prevalence increases with age – 30% of those 85 and older.
Affect about
4.5 million people in U.S. – some research suggests that oxidative stress
plays a role in pathophysiology.
Clinical Manifestations:
Early stages: forgetfulness and subtle memory loss, small difficulties in work or
social activities. Pt can usually hide the loss of function – can start to become
depressed.
Further progression is obvious – s/s cannot be hidden.
Forgetfulness in daily activities, lost ability to recognize familiar faces, places,
objects and become lost in familiar environments. Repeat things often,
conversations are difficult and word finding occurs. The ability to formulate
concepts and think abstractly disappears. Everything is literal – concrete. Pt’s are
unable to recognize consequences and exhibit impulsive behavior.
Personality changes such as depression, suspicion, paranoia, hostility, and combative
behaviors.
Progression eventually leads to speaking skills deteriorate to nonsense, agitation and
wandering. Pts need assist in all ADL’s.
Terminal stage – patients are immobile, require total care, and death usually
results from complications such as: PNA, malnutrition, and dehydration.
Nursing Management:
Nursing interventions are aimed at promoting patient function and independence as
long as possible and safe for patient.
• Supporting Cognitive Function: Active participation in cognitive, functional
and social interaction, physical activities and communication. Calm
predictable environment, quiet pleasant speaking, clear and simple
explanation’s, memory aids and cues.
• Promoting Physical Safety: Making sure the patient has a safe home
environment where they can move about freely is most important.
Removing obvious hazards,
installing hand-rails, adequate lighting, and nightlights. Wandering behavior
can be reduced by general distraction. Restraints should be avoided due to
agitation. All activities outside of the home should be supervised and pt
should wear and id bracelet incase of separation from caregiver.
• Promoting Independence in Self-Care activities: Patients should be assisted to
remain as functionally independent as possible. Simply daily activities by
organizing into short, achievable steps so they can experience
, lOMoARcPSD|21646696
accomplishment. Direct supervision is sometimes necessary but maintaining
personal dignity and autonomy is important.
• Reducing Anxiety and Agitation: Patients can be aware of their diminished
abilities so
its important to give constant emotional support to reinforce positive self
image. Its important to adjust goals according to their declining ability. Keep
the environment familiar and noise free. Too much excitement and confusion
can be upsetting and cause combative agitated state.
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• Improving Communication: Use clear easy explanations that are unhurried.
Reduce noise and distraction when talking with them.
• Providing for Socialization and Intimacy Needs : Socialization with friends can
be comforting, but should be brief and non stressful. Reduce
overstimulation. Recreation is important but must be realistic.
• Promoting Adequate Nutrition: Patients prefer food that is familiar and that
look good to eat, food should be cut into small pieces and one dish offered
at a time to prevent
choking. Food should be served warm and checked prior to eating to prevent
burns. Patients may need to use fingers or spoons to assist them in eating, if
they are not total care. Uses of aprons are preferred to bibs to maintain
dignity.
• Promoting Balanced Activity and Rest: Adequate sleep and physical activities
are
essential.
• Supporting Home and Community Based Care: Emotional support is needed for
both family and patient as the degenerative disorder progresses. Patients can
be aggressive and combative and families do not know how to cope. It’s vital
to utilize services that provide families with support groups, education,
research and advocacy.
Lumbar puncture/MRI/CT nursing
role Lumbar puncture: AKA Spinal
Tap
What is it: Process includes inserting a needle into the lumbar subarachnoid space
(L3-L4 OR L4-L5) to withdraw CSF. It can be done to examine CSF, reduce CSF
pressure, determine presence or absence of blood, and to administer meds
intrathecally.
It important for patient to remain relaxed, a patient who is anxious will have
abnormal CSF pressure readings.
Normal CSF pressure = 50-200mm h20
CSF should be clear and colorless. Pink, frothy, bloody, may indicate a subarachnoid
hemorrhage. It can also be bloody initially because of the initial trauma but as you
aspirate it will clear up.
Positioning: Patient is placed in lateral recumbent position (laying on side with either
one knee/both flexed up to chest as much as possible to increase space between the
spinous process of the vertebrae and easier access to subarachnoid space).
Pre-procedure: Obtain consent. Explain the procedure to the patient and all
sensations (cold while cleaned, small prick when needle inserted, etc). Reassure the
patient that the needle does not enter the spinal cord and does not cause paralysis.
Determine whether the patient has fully understood and if there are any more
questions. Patient should void before procedure.
Procedure: patient is positioned on one side of the edge of the bed in a lateral
recumbent position with knees flexed to increase the space between the spinous
processes for easier entry. Nurse assists in maintaining the position and preventing
sudden movements. Patient is instructed to relax and breathe normally because
hyperventilation can cause differences in pressures. The nurse describes the
procedure step by step. Physician cleanses the site, drapes the area, and
administers local anesthetic. A needle is then inserted where a pressure at that
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