ELEVEN-SYSTEM MEDICAL ASSESSMENT
The body can be
described as being comprised of eleven systems. Each system is made up of organs, and each
organ is further broken down into many tissues and innumerable cells. Systems are organized groups of structures
classified as to performing a function, as follows:
· Nervous system
· Respiratory system
· Cardiovascular system
· Lymphatic and immune
system
· Gastro-intestinal
system
· Endocrine system
· Reproductive system
· Urinary system
· Integumentary system
· Skeletal system
· Muscular system
These systems and their
disorders are discussed in this and later chapters, with an emphasis on those
conditions likely to result in long-term nursing care at home.
The nervous
system is comprised of the brain, spinal cord, nerves, and sensory organs such
as the eyes and ears. From impulses received from outside the body
due to tactile stimulation from the skin, to inside communications via
hormones, nerves, sensory organs, blood and lymph transmit these messages to
the brain via the spinal cord and integumentary (skin) system. In the brain the impulses are translated into
fine or gross motor responses as well as active or reactive actions in response
to adverse or pleasurable stimuli. The brain also houses memory, cognition,
language and many other sophisticated methods of communication and
understanding all by way of nerve impulses.
Some of the various nervous systems
conditions and care considerations appear below.
Cerebrovascular Accidents (CVA), commonly referred to as
“strokes,” are common, with 800,000 diagnosed yearly. They rank fourth as a leading cause of
death after heart disease, cancer, and pulmonary diseases. (Recently, some medical specialists have
listed medical errors as the third largest cause.) Loss of neurological function can be sudden
or gradual due to a long-term bleeding incident into the brain. Most
strokes result from a blood clot that either originated in the brain
(thrombosis) or traveled to the brain (embolus). Once the clot occludes a brain vessel, the
area no longer receives enough oxygen, causing a cerebral infarction (tissue
death). Brain hemorrhages are another main cause of strokes and can occur
by a tear in a vessel wall, hypertension, or from an injury. As bleeding continues, pressure is placed on
the brain tissues, causing brain tissue damage. Loss of blood flow to the brain
results in injury to various parts of the body, causing neurologic deficits. The injury may be temporary and resolve over time
or cause long-term or permanent disability.
The extent and location of the region of the body that is impaired is
solely determined by the area of the brain that was damaged. As all bodily functions are controlled by
the brain, the possibilities are endless.
Care
Considerations for Cerebrovascular Accidents:
1) Paralysis or decreased function to one side of the body
(hemiplegia), to one or both lower, or to one or both upper extremities can
occur. Activity difficulties may also be
due to loss of sensation, simple weakness, or changes in muscle tone (being
spastic or flaccid). Loss of fine or
gross motor skills could be apparent.
Depending on the injury, various devices could prove helpful, including
canes and wheelchairs, as well as many other occupational therapy aids.
2) Elimination patterns may be altered and could encompass
voiding and/or defecation.
Catheterization, whether intermittent or continual, may be required if
bladder retraining is unsuccessful.
Bowel evacuation might be accomplished by use of medication, enemas, or
laxatives if retraining proves ineffective.
3) Obtaining the proper amount of nutrients and fluids
could be problematic due to lack of appetite, nausea or vomiting, dysphagia
(inability to swallow), loss of sensation in the mouth and throat, medication
side effects, or facial paralysis. If
insufficient quantities are consumed, a percutaneous gastric feeding tube could
be placed for long-term use.
Shorter-term aids include centrally placed venous catheters for total
parenteral nutrition (TPN ).
4) Perception and sensory deficits are often present. These may include vision difficulties such as
blurred or double vision (diplopia).
Partial loss of vision (monocular blindness) or total blindness could
also result. Disturbances to taste and
smell are reported. Touch and skin
sensations are often not discriminated, and loss of feeling (neuropathy) could
lead to unknowingly received injuries.
Dysphasia (decreased speech capacity) may take the form of difficulty
producing speech (expressive), understanding speech (receptive), or both
(global). Aphasia is an inability to
communicate via speech, but also includes inability to understand writing and
signs or pictures.
5) Cognitive function impairment includes inability to
recognize: faces (prosopagnosia), speech
versus not speaking sounds (auditory agnosia), objects (visual agnosia), colors
(achromatopsia), and visual objects (visual agnosia) to name a few. Apraxia is the inability to use objects
properly when there is no muscle deficit.
6) Skin care is
essential due to possible incontinence, paralysis, lack of sensation, and
inability to ask for assistance.
Alzheimer’s and Dementia
The severity and
increasing prevalence of these neurological conditions are evident in these
quotes from the Alzheimer’s Association’s alz.org/facts (our emphasis added):
·
Alzheimer’s disease is the only cause of death among the
top 10 in America that cannot be prevented, cured, or even slowed.
·
Today, more than 5 million Americans are living with
Alzheimer’s disease, including an estimated 200,000 under the age of 65. By
2050, as many as 16 million will have the disease.
·
You can use the free, online Community Resource Finder to
easily locate Alzheimer’s and dementia resources, programs, and services in
your area. To learn more about this comprehensive resource for people facing
Alzheimer’s or other dementias, visit alz.org/crf.
·
The Alzheimer’s Association’s 24/7 helpline provides
reliable information and support to people living with Alzheimer’s or other
dementias, caregivers, health care professionals, and the public. Call
toll-free, anytime, day or night, at 800.272.3900.
·
Since 1982, the Alzheimer’s Association has committed over
$340 million to more than 2250 scientific investigations with the goal of
identifying novel approaches to diagnosis, treatment and – one day – a cure.
· Warning Signs of Alzheimer’s (alz.org):
§ Memory loss that disrupts daily life.
§ Challenges in planning or solving problems.
§ Difficulty completing familiar tasks at home, at work, or
at leisure.
§ Confusion with time or place.
§ Trouble understanding visual images and spatial
relationships.
§ New problems with words in speaking or writing
§ Misplacing things and losing the ability to retrace steps.
§ Decreased or poor judgment.
§ Withdrawal from work or social activities.
§ Changes in mood and personality.
Care Considerations for
Alzheimer’s and Dementia:
Gary Joseph LeBlanc (2013) has written
a clear and concise little book, Managing Alzheimer’s and Dementia
Behaviors: Common Sense Caregiving, which stresses the following:
Early warning signs of Alzheimer’s include
regular difficulties in recalling: dates, appointments, familiar names, and
information given minutes before. Reading and numeracy may suffer markedly,
despite a flood of excuses.
Hospitalization is disruptive and
enhances their confusion.
Dementia is a general term for
cognitive and memory loss, and Alzheimer’s is one of the possible causes.
Early-onset Alzheimer’s afflicts about a
half-million people under the age of 65 and is more heritable than the more
prevalent Alzheimer’s.
Such
patients benefit greatly from the maintenance of routines.
Early in the
progression,
patients can have their thoughts readily redirected. Later, this becomes nearly
impossible.
Approach these patients
slowly,
gently, looking to see if they recognize you. Introduce yourself, even to
family.
Be prepared not to be
recognized
or only after long delay.
Go with the flow. “You cannot move them
to your world, you have to move into theirs.”
Be prepared for their
hallucinations
and delusions. Exhibiting your frustration will only exacerbate the situation.
Don’t debate, elude. “I just went out and
checked. They must have moved.”
Delusions are false
beliefs.
Hallucinations
are false perceptions.
Keep the environment
well lit,
for safety and to reduce “sundowning.”
Allow your patient a
full-minute delay
in responding to you.
Communicate
face-to-face,
not on the run or at a distance.
Be alert to pain versus frustration.
Avoid combat. Retreat. Don’t take verbal
abuse personally.
Most important asset of a caregiver: patience, patience, patience.
Mr. LeBlanc’s little book is a bargain
at amazon.com for those dealing with such patients. See also the excellent book
by Scallan (2015), outlined in our Appendix.
Also, very highly regarded is the much
longer (384 pages) book, The 36-hour Day: A Family Guide to Caring for
People Who have Alzheimer Disease, Related Diseases, and Memory Loss, 5th
Edition (2011), by Nancy L. Mace and Peter V. Rabins, originally published
in 1981. It is available in ebook, paperback, audio book, and hardcover
editions.
On a personal note, this afternoon,
when I [DWC] came to check on my wife and give her a kiss, she asked, “What’s
your name?” Yesterday, she told me she loved me. Tomorrow? Recently, as I
pushed her in the wheelchair along the path through our park-like setting, she
said she would like to live to be 100. I commented that would be 29 more years
and asked her if she was enjoying her life, and she replied that she was.
Epilepsy (aka Seizure Disorder) is an abnormal electrical discharge of brain
neurons which may be hypersensitive and react to unknown chemical or
environmental stimuli. Seizures may also
occur due to metabolic disorders such as hypoglycemia or hyponatremia (deficits
in sugar or salt, respectively), infections such as meningitis, fever, drug and
environmental toxins, or trauma. They
may be unrelated to any known activities or causes, thereby making it difficult
to ascertain origins. Patients may
experience brief loss of consciousness and/or whole-body convulsions lasting
many minutes.
Care
Considerations for Epilepsy:
1) Patient may state he has “aura” which may signal an
attack. Precipitating signs may include
pungent smells, nausea, dreamy feelings, and visual disturbances as flashing
lights.
2) Patient my experience fear and shame during
seizures due to lost bodily functions; fear from inability to control or
predict seizure.
3) Due to loss of consciousness, orient patient,
explain slowly.
4) Anoxia (loss of oxygen) can occur. During and after seizure, monitor oxygen
saturation.
5) Inspect body for any injuries.
6) Lasting safely modifications may need to be enacted
which may include perceived loss of freedom by patient, such as restricted
driving. Expect some loss of “self” and
independence.
7) Consider adding padding, removal of rugs, and improving
the availability of suction apparatus.
8) A medical alert bracelet, along with wallet
medication information, is imperative.
Parkinson’s disease is a neurological impairment leading to a slow
decline in muscle function. It leads
to progressive muscular rigidity and decrease in movement (akinesia), and
involuntary tremors. Often,
initiating ambulation is difficult, and the patient is “stuck” and unable to
move. This is a hallmark of the
disease. Once initiated, the patient’s
gait gains momentum that cannot be easily controlled. Tremors are evident and often appear when the
extremity is at rest. There is often a
unilateral “pill-rolling” tremor. As the
disease progresses, it affects the other muscular systems, such as digestion
and elimination. Causes of the disease
are unknown. This is a disease that
affects purposeful muscles versus involuntary muscle movements.
Care
Considerations for Parkinson’s Disease:
1) Tremors are
prevalent but decrease during purposeful movements. Patients should utilize all muscles in both
upper and lower extremities.
2) In many instances, the
body is bent forward to initiate movement because it is difficult to get
the body in motion. Time and patience
are required to initiate motion.
3) While walking, a
potential for fall can easily result, due to the bent body position, inability
to alter course quickly, and lack of peripheral vision fields due to forward
intent. Once in motion, patient
cannot quickly react nor avoid obstacles.
4) Other injuries resulting from lack of
movement include bedsores and urinary tract infections (UTI ).
5) Assess for
additional deficits, including loss of balance, speech difficulties
(dysarthia), and problems with eating and swallowing (dysphagia).
6) Obtain evaluation of
level of consciousness.
7) As this is typically
a disease of the muscles and not of the mind, psycho-social evaluation
is paramount.
Multiple Sclerosis (MS) is an autoimmune disease causing defects in the
myelin sheath that insulates the nerves that conduct electrical impulses from
the brain and the spinal cord (the central nervous system). Lack of this myelin insulation
(demyelination) is similar to a road under construction: impulses may be slowed
greatly or blocked completely rather than traveling at a high speed to get to
their destination. MS affects the nerves
of the eyes and spinal column primarily, but the deficits are not limited to
them. However, nerves of the peripheral
nervous system are not involved. Often
the disease takes years to diagnose due to the characteristic exacerbations and
remissions that the disease presents.
Signs and symptoms of exacerbations may be transient or last for long
periods and may eventually become chronic.
The resulting disabilities depend on the location and extent of the
demyelination, and on what remyelination occurs after an exacerbation.
Care
Considerations for Multiple Sclerosis:
1) During
exacerbations, treatment is supportive, depending on the location
affected. This typically includes bed
rest, prevention of pressure ulcers, along with bowel and bladder
management.
2) Monitor ventilation and promote deep
breathing and coughing to eliminate stasis of secretions since respiratory
muscle can be affected. Monitor oxygen
saturation. Provide incentive spirometer
for visual reading of deep breathing. Be
aware for signs and symptoms of pneumonia.
3) Muscle weakness,
spasms and hyper-reflexia (over-reaction to stimuli) may occur. Ensure precautions for fall potential and
injuries, difficulties swallowing (dysphagia) and potential for aspiration
pneumonia, poor gait (ataxia) and speed.
4) Patient
may experience paralysis: monoplegia, hemiplegia, or quadriplegia
(paralysis to one extremity, one side, or all extremities, respectively). Patient safety and care issues are
paramount. Frequently aid in or provide
range of motion exercises to keep joints fluid and prevent contractures. Prevent foot drop by utilizing high-top footwear. Utilize aids, such as canes and other
rehabilitating equipment, to encourage self-care.
5) Visual
disturbances are frequent. These can
range from peripheral vision loss, to blurred vision, to complete
blindness. Assess for vision
disturbances prior to ambulation or activities of daily living.
6) Promote bowel and
bladder elimination, and prevent harm to skin from incontinence by using
frequent adult diaper changes, skin barrier creams or ointments, frequent
turning and positioning.
7) Reassure patient about loss of function
he is experiencing but make no guarantee that function will be restored. Remissions often occur with this disease, but
such are not necessarily complete.
Myasthenia Gravis is an autoimmune disease that effect the nervous
system and exhibits as a periodic, progressive, and extreme weakness of
voluntary muscles, which are the group of muscles which we “choose” to
utilize for activities. Primarily affecting muscle of the face, lips, eyes, and
the activities of chewing and swallowing (mastication), and speech, this
disease can affect any skeletal muscle in the body, including those for
ambulation. This disease prohibits the
conduction of the nerves to the voluntary (skeletal) muscles, and exacerbations
occur during repetitive use of those muscles.
A very simplified explanation is that there’s no gas left in the tank to
make the car (skeletal muscle) run. It is a disease of exacerbations and
remissions; often, symptoms worsen during the day but are improved after
resting the affected muscle group.
Extreme muscle fatigue that lessens with rest is one of the hallmarks of
this disease. There is no cure, but most
patients tend to live relatively normal lives, especially when they know their symptoms,
recognize them, and can provide the rest that is necessary to abate
exacerbations.
Care
Considerations for Myasthenia Gravis:
1) As medications
are not effective, there is no “fix” for this disease. The patient must understand that knowledge of
his body will be the main treatment.
2) Knowing outward
symptoms by the patient and family may provide signs of over-exerted
muscles caused by the blocked and weakened transmission of nerve impulses to
the muscles. For example, a dropping
or drooping of the eyelid is often evidence of a potential exacerbation. Prior to the drooping, the patient may be
tilting his head back to see better due to the muscle weakness of the eye
because the visual field is lessened by the eyelid interference.
3) Attention should be paid to breathing and
ventilation, especially during exacerbations. The respiratory muscles can often be
compromised, and this could result in hypoventilation. Not breathing deeply and fully
due to reduced muscle accessibility, both inhalation (breathing in) and exhalation
(breathing out), decreases could potentially lead to dangerously decreased
oxygen input and carbon dioxide output.
In addition, with prolonged decreases in ventilation, respiratory tract
infections could develop, including pneumonia.
Assess oxygen saturation; promote use of incentive spirometer to
encourage deep breaths and full expansion of lungs, and monitor level of
consciousness and awareness.
4) Promote an
environment and personal security that allow and encourage rest when
needed.
5) Understand that
loss of ability due to continued activity, debilitating muscle fatigue, and
the losses associated with “wanting to do” but simply “cannot even consider”
lead to loss of self-esteem. Encourage
patient to schedule down-time.
Traumatic Brain Injuries (TBI) produce a range of
disturbances, from short-term and slight trauma resulting in no apparent
damage, long-term brain dysfunction leading to life-long impairment, to a
vegetative state in the most extreme cases.
These are injury-induced conditions which cause neurological damage and
do not stem from illness or disease. A
variety of accidents can cause TBIs, including sports injuries, playground
falls, motor vehicle accidents, lack of oxygen (hypoxia), falling off ladders
or down stairs. Recovery from any brain
injury varies according to the area of the brain impacted as well as the
wellness of the individual and how well the patient reacts to treatment and
therapy. Examples of these brain
injuries include concussions, skull fractures, and hemorrhages.
Care
Considerations for Traumatic Brain Injuries (TBIs):
1) Constant
assessment is necessary to determine actual consequences of the
injury. Time will indicate acute
deficits or chronic conditions.
2) Areas of the
injured brain dictate deficits, and these may include motor skills
(weakness, loss of balance, unsteady gait or ataxia, paraplegia, and
quadriplegia), sensory changes (blurred vision, decreased acuity, blindness,
loss of taste or smell, hearing difficulties, and tinnitus), behavior changes,
bowel and bladder incontinence, dizziness or fainting (syncope), swallowing
difficulties (dysphagia), chronic headaches, increased sensations to or loss of
awareness of various body parts, increased or decreased reflexes, speech
difficulties (expressive aphasia, receptive aphasia, anomia), or breathing
difficulties.
3) Physical and
occupational therapy is often necessary.
Rest should be provided between care and therapy to promote maximum
effectiveness.
4) Slow-talking and
short-term therapy can aid in decreasing frustration associated with slow
progress of therapy.
5) Ensure airways
are protected if gag and swallowing reflexes are impaired.
6) Encourage deep
breathing to promote lung expansion and ventilation.
7) Avoid coughing,
straining or bearing down which can increase intracranial pressure.
8) Provide skin care
and equipment to decrease risk of pressure ulcers. Turn and position body frequently. Provide an air mattress to increase
circulation and decreases stasis of blood.
9) Assist with range
of motion exercises to avoid deep venous thrombosis.
Guillain-Barre’ Syndrome is thought to be an immune disorder that affects the nervous
system. It is hallmarked by acute
and rapidly progressing loss of peripheral nerve transmissions to muscles
due to demyelination. This results in
muscle weakness, immobility, and paralysis beginning in the legs and
ascending to the arms, body trunk, and face.
Often respiratory muscles are affected which hampers breathing. The disease process takes three distinct
phases: The “acute phase” begins
when the first symptoms develop and continues until no further deterioration or
loss of function is noted. This phase
may last anywhere from one to three weeks typically. During the next few days to weeks, the
“plateau phase” occurs. No further loss
of function is noted but there is also no betterment. The last phase, “recovery phase” can last
months to years but recovery is usually complete. This is the time when remyelination occurs
and growth of peripheral nervous tissue takes place.
Care
Considerations for Guillain-Barre’ Syndrome:
1) As the muscles
necessary for respiration may be involved, assessment must be ongoing to
determine loss of function. While the
patient is recovering, provide use of incentive spirometer to promote lung
expansion.
2) Paralysis of any
or all extremities is likely.
Provide skin care, turn and position, and inspect skin for any breakdown
or presence of any deep venous thrombi (DVT, blood clots); check for swelling,
reddening, warmth, suddenly visible veins.
3) Provide gentle
massage to the extremities. Deep
massage is not performed due to the possibility of DVTs.
4) If facial muscles
are involved, provide oral care frequently. It is possible that eyelids will not close
properly and completely. Instill eye
drops to lubricate them.
5) During recovery when
physical and/or occupation therapy is provided, ensure rest is given
between sessions to promote maximum benefit.
Sensory Deficits can occur with any disease or injury of the nervous system
but are not limited to this system solely.
Sensory functions include hearing, vision, speech, taste, smell, and
tactile sensitivity. While some
modifications to the environment or use of tools may minimize the deficit, this
is not the case with deficiencies in taste and smell.
Care
Consideration for Sensory Deficits:
1) Hearing
Difficulties: Deafness, whether
partial or complete, is not only disease-induced but also results from age,
environmental noise, medications and viruses.
Hearing aids may help mitigate the problem, but other useful measures
include using subtitles on the television, speaking directly to the patient so
visualization of the lips is possible, speaking clearly and slowly, and
decreasing background noise.
2) Vision
Difficulties: There are many forms
of vision deficits; these include decreased acuity, double vision (diplopia),
light sensitivity (photophobia), blurred vision and loss of the visual
field. There are few measures that can
be taken to decrease this state.
Utilization of trained professionals can provide teaching to enhance
life. However, dependent on the
severity, large print face, recorded books, and bright lighting may prove
beneficial to some.
3) Speech Difficulties: These could be simply the inability to utter
sounds (muteness) or a brain impairment called aphasia, the inability to
communicate using speech, writing, or signs.
It is almost as if communication is attempted between two people speaking
two different and unrelated languages.
Aphasia can take the form of being receptive (lack of understanding of
words spoken by others) or expressive (inability to speak in meaningful and
proper words). Anomia is the inability
to recall names of objects. If the
patient has some ability such as reading, communication can be maintained via
use of written words or signs. Time and
continued education may be beneficial.
Frustration and anxiety are common.
4) Tactile Sensitivity: Paresthesia is caused by injury to the
nerves. If it often painful and
unpleasant, and described as a numbness, stinging, tingling, or burning. While there is little that can be done other
than medications, running water over the appendage, wax dips, and massage can
decrease the discomfort.
###
Contact information:
Diane R. Beggin, RN
40 Sycamore Drive
Montgomery, NY 12549
