CHAPTER 19. The Mentally and Physically Challenged Patient
Theresa Clifford
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. List special considerations in interviewing the mentally challenged patient.
2. List different stages of Alzheimer’s disease and manifestation of limitations in each stage.
3. State effective communication techniques to use with the hearing impaired.
4. Identify techniques to facilitate learning and reduce apprehension for visually impaired patients.
5. Identify manifestations of select physical disabilities and incorporate management of these symptoms and risks in the nursing plan of care.
6. Identify effective techniques related to caring for the pediatric patient with intellectual and/or physical challenges.
I. OVERVIEW
A. According to the Americans with Disabilities Act (ADA) of 1990, a person is considered to have a “disability” if that individual has:
1. A physical and/or mental impairment that substantially limits one or more major life activities
2. A recorded history of such impairments
3. Perceived by others as having such impairments
B. Health care providers and institutions are required to offer the disabled patient full and equal access to the facility’s:
1. Goods
2. ervices
3. rograms
4. Activities
C. Patients with disabilities present significant challenges in providing quality nursing care.
D. Perianesthesia standards for ethical practice require that quality care be given to all patients regardless of their disabilities.
II. THE MENTALLY CHALLENGED PATIENT
A. Communication considerations
1. Communication: an act by means of which one person conveys to another his or her ideas, thoughts, needs, or feelings
2. A person must have some communication channel open to convey information to those around him or her.
3. Communication involves:
a. Getting information to the brain
b. Processing the information
c. Transmitting the brain’s response
4. Normal channels of communication may not be available.
5. Mental ability may be impaired from birth or acquired as a result of disease or injury.
a. Congenital defect
b. Infectious process
c. Trauma
d. Manifestation of a medical problem
e. Psychiatric disorder
6. Level of impairment of developmentally disabled
a. Mild—85%
(1) Slow learner
(2) Rarely asks questions
(3) Answers questions with a minimum of words
(4) Usually functions at a 10-year-old level
(5) Minimal impairment in sensorimotor areas
(6) Usually achieves academic skills necessary for minimum self-support
b. Moderate—10%
(1) Has little or no speech
(2) Understands and can follow simple commands
(3) Can learn simple tasks; may need supervision to perform
(4) May be able to function at a 2- to 6-year-old level
(5) May perform unskilled or semiskilled work under supervision
c. Severe and profound—5%
(1) May learn to perform simple self-care tasks with supervision
(2) Shows basic emotional response
(3) May cause self harm
(4) May function at a 2-year-old level or less
7. Cognitive considerations of the mentally challenged patient
a. Degree of impairment will determine method of instruction.
b. Simple words and phrases are more likely to be understood than complex words and ideas.
c. Common traits
(1) Short attention span
(2) Decreased retention capability
(3) Decreased sensory capability
d. Instructions may be taken very literally.
(1) May need to have basic concepts deconstructed to the essence
(2) Instructions should build on this basic essence.
e. Becomes confused and distracted easily
f. Fearful of changes in environment, loss of familiar routine
g. May have a history of previous bad experiences with health care
8. Mental status—patient may:
a. Be agitated
b. Show aggression
c. Not exhibit any response
d. Have delusions, hallucinations, and/or paranoia
9. Sensory function—patient may have:
a. Visual deficits
b. Auditory deficits
c. Asthenia
10. Communication problems
a. Poor articulation, especially consonants
b. More inarticulate when upset, frustrated, or discussing emotionally charged information
c. Use words that he or she does not really understand.
d. Be eager to please and say what thinks interviewer wants to hear.
e. Need extra time to formulate answers
f. Use sign language, read lips.
g. Use nonverbal forms of communication.
B. Improving communication successes
1. Determine the patient’s strengths and weaknesses.
2. Show respect to the patient.
a. Do not talk down to the patient.
b. Determine the “age appropriateness” of words, remembering not only the “calendar age” of a person but the “mental age” as well.
c. Maintain good eye contact.
3. Be sensitive to nonverbal communication.
a. Do not cover or hide your mouth.
b. Do not mimic how the patient pronounces words.
4. Allow adequate time.
a. Remain calm, relaxed, and unhurried.
b. Maintain a low volume.
c. May need to repeat information
d. May need to reformulate the question
5. Use the name to which the patient is accustomed.
6. Be aware that some patients may have delusions, hallucinations, and/or paranoia.
a. Approach in a calm, nonthreatening, reassuring manner.
b. Avoid activities that may feed into abnormal thinking.
(1) No sudden movement
(2) Avoid standing too close.
(3) Do not whisper or joke in patient’s presence.
(4) Do not show signs of impatience.
(5) Do not touch the patient.
(6) Challenge or agree with patient’s delusions, hallucinations, or paranoia.
7. Communicate slowly and clearly.
a. Use open-ended questions.
b. Be prepared to reword questions if the patient does not grasp the meaning of what is being asked.
c. Avoid running words together.
d. Provide a small pause between words if the patient seems to be struggling.
e. Opt for simple words instead of ones that are complex. The more basic a word is, the better the chance is that it will be understood.
f. Maintain eye contact when possible.
8. Encourage and allow patient independence according to abilities.
9. Include family and caregiver in planning care and instructions as appropriate.
10. Demonstration may be more effective than verbal explanations.
11. Provide frequent reinforcement.
C. Preadmission, preoperative interview and management
1. An in-person interview is preferable to a telephone interview.
a. Nonverbal communication may be as important as verbal communication.
b. Face to face may be a good way to communicate with the person.
c. Allow adequate time for the interview and assessment.
(1) Engage patient to increase desensitization to setting.
2. Determine the patient’s functional ability and needs.
a. Conduct developmental assessment if appropriate.
b. Include the family’s and caregiver’s perceptions about the patient’s abilities.
c. Assess family’s and caregiver’s successful management techniques.
d. Assess use of assistive devices (i.e., glasses, braces, hearing aid).
e. Identify most effective means of communication for the patient.
f. Determine willingness and capability of family and caregiver to participate in preoperative preparation and postoperative care.
3. Determine the patient’s, the family’s, and the caregiver’s knowledge and expectations of the proposed procedure.
4. Complete health history per protocol.
a. Cause of disability
(1) At birth or acquired
(2) Degree of disability
(a) Retains self-determination capabilities
(b) Caregiver shares decision-making.
(c) Durable power of attorney for health care
(d) Appointed legal guardian
b. Consider common health conditions associated with multiple disabilities.
(1) Alimentary—dental caries, high arched palate, gum disease, facial asymmetry, mandible subluxation, jaw and tongue asymmetry, oral sensitivity, inadequate nutrition
(2) Sensory—limited communication abilities, visual and hearing impairment
(3) Cardiovascular—reduced cardiac and lung functions linked to spinal curvature, conduction defects, cardiac anomalies
(4) Respiratory—possible history of aspiration, chronic pneumonitis, and chronic respiratory infections
(5) Musculoskeletal—spinal curvatures such as scoliosis; hyperlordosis; hyperkyphosis; deformities of shoulders, elbows, wrists and hands, knees and feet; hypertonia; hypotonia; fluctuating muscular tone; athetosis
(6) Skin—damage to skin integrity from pressure and incontinence
(7) Elimination—urinary and fecal incontinence, urinary tract infection (UTI), constipation, urinary retention, bowel impaction
(8) Central nervous system—epilepsy, seizures
c. Past illnesses—especially those for which the patient was hospitalized
(1) Coping mechanisms to handle illness-related stress
(2) Length of recuperative period
(3) Frequency of respiratory infections
(4) Normal response to pain
(5) Bladder function difficulties
(6) Bowel function difficulties
d. Other health problems
(1) Congenital heart defect and other cardiovascular disorders
(2) Diabetes—mellitus, insipidus
(3) Seizures
(a) Time of last seizure
(b) Frequency of seizures
(c) Description of seizures
(4) Elicit if any other problems.
e. Medications
(1) Current medication use
(a) Prescription
(b) Over-the-counter
(c) Herbal preparations
(d) Dietary supplements
(2) Behavior changes caused by medications
(3) Previous response to medications
f. Allergies
(1) Medications
(2) Environmental
(3) Food
(4) Latex
(5) Tape
(6) Type of reactions to allergies
g. Nutritional requirements and modifications
(1) Special dietary restrictions
(2) Food consistency
(3) Preferences
(4) Ability to swallow
(5) Ability to eat independently or amount of assistance needed
h. Usual behavior
(1) Patient’s interaction with people and environment
(2) Orientation to time and place
(3) Emotional stability
(a) Mood swings
(b) Potential for violence
(c) Panic attacks
(d) Hallucinations, delusions, paranoia
(4) State of consciousness
(5) Language ability
5. Physical assessment per protocol
a. Vital signs and oxygen saturation (vital signs usually within expected range for size and age)
(1) Past tendency for pronounced temperature deviations
b. Body size
(1) Obese
(2) Emaciated
c. Skin color and blemishes may provide clues to other illnesses.
(1) Pallor may indicate anemia.
(2) Uneven coloring and/or mottling may indicate poor neural functioning of the autonomic system.
(3) Excessive pigmentation (freckles) could indicate pathology.
(4) Multiple café au lait spots indicate neurofibromatosis (von Recklinghausen’s disease).
(5) Port wine stain on the face along the trigeminal nerve may indicate Sturge-Weber syndrome.
d. Differences in skin temperature, skin turgor
e. Defects of the craniofacial area
(1) Anatomical deformities that interfere with intubation
(2) Weakness of pharyngeal muscles
(3) Large tongue
f. Joint deformities
(1) Pain on movement
(2) Muscle strength
(3) Involuntary movements or spasms
(4) Altered stance, gait, or posture
(5) Contractures
g. Deficits in hearing or vision
6. Psychosocial assessment per protocol
a. Anxiety
(1) Fear of strange environment
(2) Loss of independence
(3) Change in daily routine
b. Support system
(1) Ensure competent and willing adult to assist with preoperative care and after discharge.
(2) May need early social service referral for discharge care
7. Develop a plan of care based on the assessment of the patient’s and caregiver’s knowledge and needs.
8. Preoperative teaching per protocol and using techniques listed in prior sections
a. Explain what will happen in simple terms.
b. Explain what to expect preoperatively and immediate postoperatively.
c. Determine the patient’s regular schedule and incorporate that schedule into the hospital routine whenever possible.
d. Include family and caregiver in the preoperative and postoperative preparations.
e. Encourage the patient to bring some familiar comfort item from home.
f. Demonstrate preoperative preparation or postoperative exercises and/or treatments and have the patient or caregiver do a return demonstration.
g. Nothing by mouth (NPO) requirements—consider harm of extensive NPO time element to patient’s emotional well-being.
h. Medications to take or hold
(1) Maintain regular dose schedule as much as possible.
(2) Keep in mind the interactions with anesthesia of tricyclic antidepressants and monoamine oxidase inhibitors when giving instructions—seek clarification from the anesthesia provider if necessary.
i. Pain scale (modify to suit patient’s learning ability)
(1) Demonstrate use of pain scale to patient.
(2) Have patient return demonstration.
j. Ensure that appropriate person will be available to sign necessary consents.
k. Ensure arrangements for safe transport to and from the hospital.
l. Ensure that there will be a responsible adult to assist with care after discharge.
9. Complete preparation for admission per protocol.
a. Make referrals as necessary.
b. Preoperative testing as ordered
c. Document and communicate special needs to the perianesthesia staff.
D. Day of admission (Box 19-1)
BOX 19-1
ADMISSION PROCEDURE
▪ Review data collected during preadmission interview.
▪ Verify compliance to preoperative instructions with patient, family, and caregiver.
▪ Verify safe transportation home and competent adult help at home.
▪ Verify consents are appropriately signed.
▪ Perform physical assessment (history and physical per policy).
▪ Provide emotional support to patient and family and caregiver.
▪ Institute appropriate nursing measures to decrease anxiety.
▪ Decrease stimulation in the waiting area.
▪ Limit number of personnel who interact with the patient while providing continuity.
▪ Allow family and caregiver to remain with the patient as long as possible.
▪ Allow patient to use assistive devices as long as possible.
▪ Consider preoperative medications to decrease anxiety.
▪ Consider applying topical anesthetics at least 1 hour before IV insertion.
▪ Maintain a calm, unhurried, and accepting attitude.
▪ Call patient by name he or she is most familiar with.
▪ Allow patient to take comfort item to surgery if permissible.
▪ Prepare patient for procedure per protocol.
▪ Communicate patient’s special needs to all members of the health care team (surgical, anesthesia, and perianesthesia team members).
IV, Intravenous line.
E. Preoperative holding and intraoperative (Box 19-2)
BOX 19-2
PREOPERATIVE HOLDING AND INTRAOPERATIVE
▪ Whenever possible, have the PACU nurse meet the patient beforehand so that the patient will recognize and be comforted by a familiar face in an unfamiliar and frightening environment.
▪ Review collected data.
▪ Provide routine care per protocol.
▪ Provide emotional support.
▪ Use the name with which the patient is familiar.
▪ Reassure the patient you are with him or her; touch patient if it will provide comfort.
▪ Allow patient to keep comfort item.
▪ Whenever possible, allow patient to keep hearing aid, glasses, etc.
▪ Maintain normothermia, taking care not to overheat.
▪ When moving patient, lift rather than pull, especially if joint deformities are present.
▪ Communicate the patient’s special needs to the PACU staff.
PACU, Post anesthesia care unit.
F. Phase I (Box 19-3)
BOX 19-3
PHASE I
▪ Review collected data.
▪ Provide routine care per PACU protocol and ASPAN Standards.
▪ Be alert for agitation, disorientation, or combative behavior.
▪ Minimize risk of aspiration.
▪ Observe for return of gag and swallowing reflexes.
▪ Elevate head of bed if not contraindicated.
▪ Suction as necessary.
▪ Position on side if not contraindicated.
▪ Provide for safety—use restraints for protection only as a last resort to prevent injury (refer to facility policy on restraint use).
▪ Assess frequently for pain, administer medication, and monitor response as indicated.
▪ Recognize patient may not be able to tell you pain is present.
▪ Be attuned to nonverbal communication.
▪ Provide emotional support.
▪ Use the name with which the patient is familiar.
▪ Provide reassurance to the patient that you are present.
▪ Allow use of comfort item if sent with a patient.
▪ Reorient patient to surroundings.
▪ Allow use of assistive devices as soon as possible.
▪ Have a family member and caregiver with the patient if possible.
▪ Communicate patient’s special needs to phase II team.
ASPAN, American Society of PeriAnesthesia Nurses; PACU, post anesthesia care unit.
G. Phase II (Box 19-4)
BOX 19-4
PHASE II
▪ The patient may return to phase II directly from the operating room (fast-tracking).
▪ Patient may be disoriented, combative, or agitated.
▪ Review collected data.
▪ Provide routine care per protocol and ASPAN Standards.
▪ Minimize risk of aspiration.
▪ Observe for return of gag and swallowing reflexes.
▪ Elevate the head of bed if not contraindicated.
▪ Suction as necessary.
▪ Position on side if not contraindicated.
▪ Use caution when giving liquids or solids.
▪ Assess for pain level per protocol.
▪ Use a pain scale that is appropriate for the patient.
▪ Medicate as needed and observe for response.
▪ Use relaxation methods as appropriate.
▪ Document reactions to interventions.
▪ Provide emotional support.
▪ Allow family and caregiver to be with patient as soon as possible.
▪ Allow use of assistive devices as soon as possible.
▪ Reorient to surroundings.
▪ Prepare for discharge.
▪ Verify safe transportation home and competent adult to care for patient at home.
▪ Include family and caregiver when reviewing instructions; if a procedure is to be done at home, have patient or caregiver perform a return demonstration.
▪ Recognize the possible need to give instructions to protect operative site based on patient’s psychological needs.
▪ Provide written as well as verbal home care instructions.
▪ Use large type if necessary for written instructions.
▪ It may be necessary to use a tape recorder if reading skills are inadequate.
▪ Obtain a phone number to reach the patient and caregiver for postoperative follow-up phone call.
▪ Give appropriate phone numbers so the patient and caregiver can obtain assistance if questions or problems arise at home.
ASPAN, American Society of PeriAnesthesia Nurses.
H. Postdischarge (Box 19-5)
BOX 19-5
POSTDISCHARGE
▪ Contact patient and caregiver within 24 hours of discharge.
▪ Identify yourself and state purpose of the call.
▪ Identify compliance with postoperative instructions.
▪ Identify potential complications:
▪ Unrelieved pain and nausea
▪ Unexpected or excessive bleeding or swelling
▪ Elevated temperature
▪ Redness or drainage from operative site
▪ Other adverse occurrences
▪ Refer to appropriate physician or agency as necessary.
▪ Complete postdischarge assessment per facility protocol.
III. ALZHEIMER’S DISEASE
A. Background information
1. Alzheimer’s disease (AD): a complex progressive, ultimately fatal, neurodegenerative disorder.
a. Certain types of nerve cells in particular areas of the brain degenerate and die.
b. Affected cells include cortical pathways involved in:
(1) Catecholaminergic
(2) Serotonergic
(3) Cholinergic transmission
c. Advancing pathology leads to the classic clinical symptoms.
(1) Memory loss
(2) Changes in personality
(3) Noticeable decline in cognitive abilities (including speech and understanding)
(4) Loss of executive function (decision-making)
(5) Losses impairing activities of daily living (ADLs; dressing, eating, toileting, etc.)
d. Most common cause of dementia in people 65 years or older
2. Stages of progression
a. Forgetful stage—changes in:
(1) Short-term memory
(2) Depression
(3) Conflict with others
(4) Expressive aphasia
(5) Frustration
b. Confused stage:
(1) Agnosia (inability to recognize common objects)
(2) Decreased time sense
(3) Withdrawn
(4) Impaired reading abilities
(5) Difficulty managing daily activities (money, driving, cooking, cleaning)
(6) Wandering, night walking, walking without lifting feet
(7) Belligerence
(8) Confusion
(9) Paranoia
(10) Agitation
(11) Delusions
(12) Aggression
c. Demented stage:
(1) Loss of ability to perform ADLs
(2) Decreased awareness
(3) Repetitive behaviors
(4) Decline in language ability
d. End-stage dementia—loss of purposeful mobility, loss of communication, dependence in ADLs. Patient is at risk for:
(1) Contractures
(2) Weight loss
(3) Skin breakdown
(4) Repeated infections
(5) Aspiration
3. Treatment—stabilize symptoms and minimize or prevent behavioral problems.
a. Acetylcholinesterase inhibitor drugs temporarily delay worsening cognitive symptoms.
(1) Donepezil hydrochloride (Aricept)
(2) Rivastigmine (Exelon)
(3) Galantamine (Reminyl)
b. Vitamin E—may delay the progression from one stage to the next
(1) Antioxidant properties
(2) Doses prescribed range from 400 to 1200 IU twice per day.
c. Behavioral modification for agitation
4. Symptoms are exacerbated by:
a. Illness, disease
b. Increased temperature
c. Dehydration
d. Medications, including anesthesia
e. Tests, treatments
f. Changes in routine
g. Unfamiliar people, sights, sounds, smells
B. Preadmission and preoperative interview and management
1. Patient may not be able to provide information.
2. Determine the patient’s level of ability with input from family and caregiver.
3. Determine the patient’s and family’s understanding of AD.
4. Determine the family’s willingness and ability to participate in preoperative preparation and postoperative care.
5. Provide a safe, comfortable environment without distraction and allow enough time for interview and assessment.
a. Include family and caregiver to decrease anxiety and agitation and increase compliance.
b. Include the patient in discussions about his or her procedure.
(1) Establish eye contact, talk in a low-pitched, reassuring tone using patient’s name.
(2) Speak slowly and clearly using short, simple sentences with familiar words.
(3) Ask one question at a time.
(4) Ask yes or no questions.
(5) Allow 20 to 30 seconds for patient to answer question.
(6) Give simple directions, one step at a time.
(7) Because of patient’s short-term memory loss, be prepared to repeat information frequently.
(8) Patient may respond to mood of situation more than words spoken.
(9) Overstimulation of environment or pressure to answer questions may make patient more confused, agitated, aggressive.
(10) Be alert to patient’s nonverbal communication.
(11) Do not leave patient alone because he or she may wander away.
6. Assessment per protocol
a. Abilities and needs of the patient
(1) Caregiver’s and family’s successful management techniques
(2) Use of assistive devices
(3) Effective method of communication
(4) Normal daily routine for patient
b. Degree of disability
(1) Retains self-determination capabilities
(2) Family shares decision-making.
(3) Has durable power of attorney for health care
(4) Legal guardian appointed
7. Complete health history per protocol
a. Swallowing problems
b. History of aspiration
c. Triggers for agitation
8. Physical assessment per protocol
a. At risk for aspiration caused by:
(1) Decreased level of consciousness
(2) Decreased cough and gag reflexes
(3) Impaired swallowing mechanism
b. Patients treated with Ginkgo biloba or vitamin E may be at increased risk of bleeding.
(1) Observe for bruising.
(2) Consult with primary care physician about stopping or adjusting dosage before surgery.
9. Psychosocial assessment per protocol
a. Support system
(1) Possible lack of support system related to:
(a) Personality changes
(b) Altered behavior patterns
(c) Depression
(d) Inability to interact in an adult manner
(e) Delusions
(f) Socially unacceptable behavior
(2) Consider early referral to social services for discharge planning.
(3) Arrangements for safe transportation to and from the hospital
(4) Arrangements for willing, competent adult in home for postdischarge care
b. Anxiety—symptom for all stages of AD
(1) One nurse as much as possible for continuity of care and familiarity
(2) State name and purpose of encounter every time.
(3) Orient patient frequently.
10. Develop a plan of care based on patient’s and family’s and caregiver’s knowledge and needs.
11. Preoperative teaching per protocol
a. Include family and caregiver—patient is likely to forget instructions.
b. Present small amount of information at one time.
c. Give written as well as verbal instructions.
12. Complete preparation for admission per protocol.
a. Referrals as necessary
b. Preoperative tests as ordered
C. Admission for procedure (see Box 19-1)
1. Provide safe, calm, unhurried environment.
a. Use one nurse for care and approach as outlined in previous section.
(1) State name and what is happening every time.
(2) Orient patient to surroundings frequently.
(3) Explain actions before proceeding.
(4) If becomes agitated, pat or hold hand gently—avoid physical contact that could seem restraining.
b. Keep bed low, side rails up, family and caregiver at bedside.
2. Cognitive assessment
a. Memory loss
b. Confusion and disorientation
c. Agitation
D. Preoperative holding and intraoperative (see Box 19-2)
1. Use care when moving the patient.
a. Lift rather than pull to protect skin.
b. Protect bony prominences by positioning and use of padding.
2. Restraints are likely to cause agitation.
a. May need sedation before applying restraints necessary for procedure
b. Will need distraction from restraints if awake
3. Patient may be at risk for aspiration—more common in the later stages of AD.
a. Elevate the head of the bed if possible.
b. Suction as needed.
c. Position on side if possible.
4. May have an impaired cholinergic system. Avoid anticholinergic medicines such as atropine and scopolamine that may result in untoward behavioral activity.
E. Phase I (see Box 19-3)
1. Pain frequently undertreated because of cognitive disability
a. Pay attention to nonverbal clues.
b. Observe carefully for response to pain medication.
2. Increased risk of bleeding if has been taking Ginkgo biloba or vitamin E supplements
3. May be agitated, combative, confused
a. Repeated orientation to surroundings
b. Use one nurse for care.
c. Use nasal cannulas rather than mask.
d. Turn down sound from bedside monitors.
e. May need to wrap intravenous line in gauze or put on stockinette sleeve
f. If nasogastric tube in place, tape behind ear and fasten to gown’s shoulder.
g. Consider dehydration as contributing cause.
h. Observe for bladder distention.
i. Allow use of assistive devices as soon as possible.
j. Return to area with family and caretaker as soon as possible.
k. Avoid restraints if at all possible.
F. Phase II (see Box 19-4)
1. May be at risk for aspiration
a. May need to remind the patient to swallow
b. Elevate the head of the bed if possible.
c. Suction as needed.
d. Position on side if not contraindicated.
e. Use caution when giving liquids and solids.
2. Patient may be confused and/or combative.
a. Frequently orient patient to surroundings.
b. Allow family and caregiver to be with patient.
c. Allow use of assistive devices as soon as possible.
d. Provide safe environment, nursing interventions as listed in prior sections.
3. Pain is frequently undertreated because of cognitive disability.
a. Pay attention to nonverbal clues.
b. Observe carefully for response to pain medication.
4. Discharge
a. Patient will benefit from returning to familiar environment as soon as possible.
b. Verify safe transportation home.
G. Postdischarge (see Box 19-5)
IV. HEARING IMPAIRMENT
A. Background information
1. Estimated 28 million U.S. citizens have hearing impairments.
a. Leading disability in America
b. Affects 30% of patients 65 years and older
c. Affects more than 50% of those older than 75
2. Definitions
a. Deaf: unable to hear or understand oral communications with or without the aid of amplification devices
b. Hard of hearing: a hearing loss severe enough to necessitate use of amplification devices to hear oral communication
3. Types of hearing impairment
a. Conductive hearing loss—reduced ability of sound to be transmitted to middle ear
b. Sensorineural—reduced hearing resulting from damage to inner ear or neural brain pathways
c. Mixed—combination of conductive and sensorineural impairments
d. Central—auditory compromise at the level of the brain
4. Hearing deficit is not reflective of low intelligence.
5. Not all hearing impaired people can read lips or use sign language.
6. Only about 20% to 30% of words are readable on the lips.
B. Techniques for effective communication with the hearing impaired in any setting
1. Provide an environment for effective communication.
a. Provide a quiet, distraction-free area.
b. Provide adequate lighting.
c. Provide interpreter if necessary.
d. Supply a battery-powered microphone with earpiece if applicable.
e. Allow patient to choose appropriate seating arrangement.
2. Get patient’s attention before speaking.
a. Approach within the patient’s line of vision; face patient directly.
b. Wave hand.
c. Touch gently as to avoid startling the patient.
3. Determine the patient’s preferred method of communication.
a. Hearing aid
b. Lip reading
c. Sign language
d. Written messages
e. Alphabet, picture, word or phrase board
f. Combination of methods
4. For lip reading and/or hearing augmented by hearing aids
a. Sit or stand directly in front of the patient.
b. Keep mouth visible when speaking.
c. Do not chew gum or food.
d. Maintain comfortable voice volume.
e. Speak slowly and distinctly; do not exaggerate your pronunciation.
f. Use smallest number of words to convey the message.
g. Maintain eye contact.
5. Working with an interpreter
a. The interpreter is used to transmit information, not to explain information or give opinions.
b. Stand or sit across from the patient with the interpreter beside you.
c. Speak at a normal tone and face the patient directly.
d. Ask the patient, not the interpreter, to clarify information if not understood.
C. Preadmission and preoperative interview and management
1. An in-person interview facilitates the patient’s participation, especially if he or she relies on lip reading or gestures.
a. Determine whether an interpreter for sign language will be needed to communicate with the patient.
b. Determine whether the patient has access to a telecommunications relay service for phone messages.
2. Incorporate communication techniques for hearing impairment.
3. Include family member in preoperative visit if possible.
4. Identify level and duration of disability.
a. Totally deaf
b. Able to hear with hearing aids in place
c. Severe decrease in hearing
(1) Is one ear better than the other?
(2) Is hearing improved by using a supplemental microphone with earpiece?
5. Provide adequate time for interview and assessment.
6. Use patient’s method of communication; provide an interpreter if necessary.
7. Determine the patient’s and family’s knowledge and expectations of the proposed procedure.
8. Assessment per protocol
a. Abilities and special needs
b. Willingness of family to participate in preparation for procedure and postoperative care
c. Use of hearing aid or other assistive devices
d. Be alert to nonverbal communication.
9. Complete health history per protocol
10. Physical assessment per protocol
11. Psychosocial assessment per protocol
a. Anxiety
(1) Feeling of isolation because of disability
(2) Fear of not understanding what is happening in a strange environment
(3) History of bad experiences in health care settings
b. Support system
(1) Arrangements made for safe transportation to and from hospital
(2) Arrangements made for competent adult help after discharge
(3) Arrangements to communicate messages to the patient
(a) Before the procedure—time changes if necessary
(b) Interpreter on hand day of surgery if needed
(c) Follow-up postoperatively
(4) If patient is primary caregiver of another person, have arrangements for help been made while patient recovers?
12. Develop a teaching plan based on patient’s and family’s knowledge and needs.
13. Preoperative teaching per protocol
a. Verify that the patient understands instructions.
(1) Ask the patient directly.
(2) Repeat or reinforce information as necessary.
(3) Provide written information to take home.
b. Explain that family can be with patient as long as possible before surgery and as soon as possible after surgery.
c. Hearing aid and/or assistive devices will be used as long as safely possible before surgery and returned as soon as possible after surgery.
d. If patient wears a hearing aid, instruct to check hearing aid battery and that aid is clear of earwax before admission.
14. Complete preparation for admission.
a. Referrals made as necessary
b. Preoperative tests as ordered
c. Arrange for interpreter day of procedure if necessary.
15. Document and communicate special needs to other members of perioperative team.
D. Admission for procedure (see Box 19-1)
1. Use communication techniques for hearing impairment.
a. Know patient’s method of communication.
b. Provide interpreter if necessary.
c. Inform patient that hearing aid or communication device will be returned as soon as possible after surgery.
E. Preoperative holding and intraoperative (see Box 19-2)
1. Use communication techniques for hearing impairment.
2. If possible, avoid covering face with mask when speaking to patient.
3. Allow use of hearing aid, communication, or other assistive devices if possible.
4. Use gestures or written messages if necessary.
F. Phase I (see Box 19-3)
1. Approach patient in his or her line of sight.
2. Gently touch patient to get his or her attention.
3. If protective lubricant used, clear from patient’s eyes.
4. Return hearing aid or other assistive devices as soon as possible.
5. Speak slowly and distinctly.
a. Remain in patient’s line of vision when speaking.
b. Keep your mouth visible when speaking.
c. Recognize that the patient will hear and understand less when tired and/or ill.
G. Phase II (see Box 19-4)
1. Return hearing aid and assistive devices as soon as possible.
2. Use communication techniques for hearing impairment.
3. Recognize that the patient will hear and understand less when tired and/or ill.
H. Postdischarge (see Box 19-5)
V. VISION IMPAIRMENT
A. Background information
1. Estimated 10 million people affected in United States
a. Seventy percent of the estimate are 65 years or older.
b. Complete blindness—no vision
c. Legal blindness—unable to see at 20 feet what normal vision can see at 200 feet
d. Partially sighted—need adaptive methods to read and write
e. Hemiplegics—may have loss of half of visual field in each eye
f. Macular degeneration—loss of sight in the center vision field, accounts for 54% of all blindness
2. May or may not have other disabilities
B. Preadmission and preoperative interview and management
1. Identify yourself and state purpose of visit.
a. Use a normal tone of voice.
(1) Sense of hearing in a blind patient is often very acute.
(2) Ask the patient if he or she can hear you before speaking louder.
b. Provide a safe environment.
(1) If moving to another area, offer arm to patient.
(a) Patient takes arm from behind, just above the elbow.
(b) Expect the patient to keep a half step behind you so he or she can anticipate if a step is coming.
(2) Orient to environment.
(a) Give specific directions such as “straight in front of you” and “directly to your left.”
(b) Introduce everyone in the room.
(c) Let the patient know what you are doing if there is silence in the room for awhile: “I need to write this down now.”
c. Assure patient his or her needs will be communicated to perianesthesia team members.
2. Identify level and duration of disability.
a. Totally blind
b. Partial vision
c. Light perceptive
d. Patient’s management skills
3. Ask the patient how much assistance he or she needs and wants in performing ADLs.
4. Determine patient’s and family’s knowledge of proposed procedure.
5. Assessment per protocol
a. Abilities, special needs
b. Desired method of communication
(1) Braille
(2) Special glasses or contacts
(3) Large print
(4) Audiotape
(5) Computer disk
c. For other disabilities
6. Complete health history per protocol
7. Physical assessment per protocol
8. Psychosocial assessment per protocol
a. Support system
(1) A competent adult who can assist at home after discharge
(2) If the patient and/or caregiver is a primary caregiver for another person, arrangements made for someone else to provide care for that person.
(3) Safe transportation to and from the hospital
b. Anxiety
(1) Isolation because of disability
(2) Fear of being left alone
9. Develop plan of care based on patient’s needs and knowledge.
C. Preoperative teaching and preparation per protocol
1. Provide instructions.
a. Verbal
b. Written—use large bold letters with black felt tip markers on white paper.
c. Audiotape—preferred method to take home
d. Need for a safe environment at the facility
(1) Side rails for safety; keep bed low.
(2) Call light will be within reach.
(3) Encourage support person to be available to stay with patient the day of surgery.
e. Assure patient of emotional support.
(1) Explain what will happen preoperatively and in the immediate postoperative period.
(a) Describe what surroundings will sound and feel like: “group room with curtain dividers,” “cold,” and so forth.
(b) Explain who will be present in the different stages of care.
(2) Availability of preoperative medications for relaxation
(3) Assure patient that staff will be within calling distance.
2. Prepare for procedure per protocol.
a. Referrals as necessary
b. Preoperative testing as ordered
3. Document and communicate patient’s special needs to perioperative team members.
D. Admission for the procedure (see Box 19-1)
1. Use communication technique in which patient is comfortable.
a. Verbal only, Braille, combination of methods
b. Get patient’s attention before speaking.
(1) Speak in normal tone of voice.
(2) Provide a quiet area to prevent distraction.
2. Promote independence based on patient history.
3. Provide description of new surroundings.
a. Identify those present.
b. Allow time and opportunity for patient to explore new environment.
4. Include patient in discussions about his or her procedure.
5. Inform patient that communication device will be returned as soon as possible after the procedure.
E. Preoperative holding and intraoperative (see Box 19-2)
1. Avoid confusion and too many people speaking at once.
2. Let the patient know who is in the room.
3. Let the patient know what is being done before touching him or her.
4. Keep the environment safe.
a. Use safety devices such as side rails and straps for stretchers.
(1) Explain to patient where the devices are located.
(2) Explain the purpose of and how the straps feel before applying.
b. Have a means for the patient to call for assistance.
c. Assure patient he or she will not be left alone.
F. Phase I (see Box 19-3)
1. Speak in a normal tone of voice.
2. Touch patient gently to get his or her attention.
3. Resume use of assistive devices if possible.
4. Maintain calm, quiet environment to decrease confusion.
G. Phase II (see Box 19-4)
1. Speak softly and gently touch patient to get his or her attention.
2. Use safety devices such as side rails.
a. Keep call light within reach at all times.
b. Allow family or caregiver in as soon as possible.
3. Discharge (see Box 19-5)
a. Provide clear discharge instructions.
(1) Provide written copy of instructions for caregiver.
(2) May need to provide audiotape of instructions
b. Instruct caregiver on visual assessment of the operative site.
VI. SPEECH IMPAIRMENT
A. Background information
1. Aphasia: language disorder that impairs the expression and understanding of language as well as reading and writing
a. Receptive: an inability to understand the spoken word due to damage of Wernicke’s area; can speak but the words do not make sense
b. Expressive: an inability to speak or write due to damage of Broca’s area; can understand what is being said
c. Usually occurs suddenly—stroke or brain injury
d. May also develop slowly—brain tumor
e. Patient may also suffer from:
(1) Dysarthria: difficult, poorly articulated speech caused by paralysis of the muscles that control speech
(2) Apraxia: inability to correctly position and sequence speech muscles to produce understandable speech
(3) Aphonia: loss of ability to produce normal speech sounds from vocal cords
2. Mutism: inability to speak caused by a physical defect or emotional problem
3. Neurological diseases can cause speech disorders.
a. Parkinson’s disease
b. AD
c. Stroke
d. Brain tumors
4. Malignant conditions may require the removal of speech apparatus.
a. May use a voice synthesizer
b. Laryngectomy patient may use controlled breathing or belching to speak.
B. Techniques for effective communication with the speech impaired
1. Keep distractions to a minimum (turn off radio, television).
2. Maintain a natural conversational manner appropriate for an adult.
3. Include the speech-impaired person in conversations.
4. Simplify language using short and simple sentences.
5. Maintain a normal voice volume.
6. Allow enough time for a response.
a. Avoid correcting the person’s speech.
b. Encourage any type of communication.
(1) Speech
(2) Gestures
(3) Pointing
(4) Drawing
C. Preadmission and preoperative interview and management
1. An in-person interview is more effective than a telephone interview and allows the patient a greater opportunity to participate.
2. Use techniques for effective communication with the speech impaired.
3. Determine the patient’s effective means of communication.
a. Use of assistive devices (i.e., glasses, hearing aid)
b. Story board, writing tablet, or slate
4. Encourage but do not pressure the patient to respond in whatever way he or she can.
a. Encourage patient to write responses, if he or she can write and spell.
b. Encourage the use of gestures if that is most effective means to communicate.
5. Allow adequate time for the interview and assessment.
a. Allow for differences in accuracy and articulation when soliciting patient’s response.
b. Present a relaxed attitude by mannerisms, patience, and acceptance.
c. One person speaking at a time helps to decrease confusion.
d. Ask direct questions requiring one-word answers.
6. Encourage family and caregiver to be present.
a. May better understand patient’s gestures and speech patterns
b. Continue to include patient in discussions.
7. Complete health history per protocol
a. Cause and duration of disability
b. Concurrent diseases that contribute to speech impairment
8. Physical assessment per protocol
9. Psychosocial assessment per protocol
a. Anxiety level—concern over ability to communicate with staff
b. Support system
(1) Willingness of family and caregiver to be present the day of surgery to assist with communication
(2) Arrangements made for patient to communicate with hospital staff from home concerning questions or changes
(a) Contact person via phone
(b) Internet and e-mail access
10. Determine the patient’s and family’s knowledge of the proposed procedure.
11. Develop a teaching plan based on the patient’s and family’s knowledge and needs.
12. Preoperative teaching per protocol
a. Use techniques for effective communication with the speech impaired.
b. Give written instructions to review at home.
13. Complete preparation for admission.
a. Preoperative tests as ordered
b. Referrals as necessary
c. Document and communicate patient’s special needs to perioperative team members.
D. Day of procedure admission (see Box 19-1)
1. Use techniques for effective communication with the speech impaired.
2. Provide enough time for the patient to communicate concerns.
E. Preoperative holding and intraoperative (see Box 19-2)
1. Allow the patient to continue to use assistive devices as long as possible.
2. Discuss with patient how he or she can make needs known or answer questions if he or she is without his or her normal communication tools.
a. Squeeze hand—once for yes, twice for no.
b. Raise hand if appropriate.
c. Give patient a bell to ring.
d. Provide writing board.
3. Reassure the patient that you are with him or her.
F. Phase I (see Box 19-3)
1. May be at higher risk for aspiration
a. Observe for return of swallowing and gag reflexes.
b. Position on side, if allowed, until return of gag and swallowing reflexes.
c. Elevate head of bed after return of reflexes if not contraindicated.
d. Suction as needed.
2. Reduce apprehension.
a. Reorient to surroundings.
b. Provide means of communicating.
c. Reunite patient and family as soon as possible.
G. Phase II (see Box 19-4)
1. Use techniques for effective communication with the speech impaired.
2. Return assistive devices as soon as possible.
3. Arrange for a contact person to phone or how to communicate with patient at home for postoperative follow-up.
H. Postdischarge (see Box 19-5)
VII. SPINAL CORD INJURY (see Chapter 33)
A. Background information
1. Classification
a. Complete—total paralysis and loss of sensation below the zone of injury, resulting in quadriplegia or paraplegia
(1) Paraplegia: the result of injury to the thoracolumbar region (T2 to L1), causing loss of motor and sensory function of the lower extremities while upper extremity function remains intact
(2) Quadriplegia: the result of injury to cervical or thoracic regions (C1 to T1), with impaired function of the arms, trunk, legs, and pelvic organs occurring
b. Incomplete—with partial preservation of function below the zone of injury
c. Measurement of functional ability: Functional Independence Measurement
(1) Seven-point scale measures 18 items in six categories:
(a) Self-care
(b) Continence of bowel and bladder
(c) Mobility
(d) Locomotion
(e) Communication
(f) Social cognition
(2) Scale of 1 equals total dependence on caregiver.
(3) Scale of 7 indicates independence.
2. Consequences of level of injury
a. C1 to C4—results in quadriplegia with complete loss of motor and sensory function from the neck down and loss of respiratory function
b. C5—results in quadriplegia and loss of all functions below the upper shoulder level; the phrenic nerve is intact but not the intercostal muscles.
c. C6—results in quadriplegia and loss of all functions below the shoulders and upper arms; no use of intercostal muscles
d. C7—results in incomplete quadriplegia with loss of motor control to parts of the arm and hand, and loss of sensation below the clavicle and parts of the arms and hands; no use of intercostal muscles
e. C8—results in incomplete quadriplegia with loss of motor control to parts of the arms and hands and loss of sensation below the chest and part of the hands; no use of intercostal muscles
f. T1 to T6—results in paraplegia with loss of motor function below the midchest, including the trunk muscles, and loss of sensation from the midchest downward, including the lower limbs; the phrenic nerve functions independently; there is some impairment of the intercostal muscles.
g. T6 to T12—results in paraplegia with loss of motor control and sensation below the waist; there is no interference with respiratory function.
h. L1 to L3—results in paraplegia with loss of most of the control of the legs and pelvic area, and loss of sensation to the lower abdomen and legs
i. L3 to L4—results in incomplete paraplegia with loss of control and function of part of the lower legs, ankles, and feet
j. L4 to S2—results in incomplete paraplegia with varying degrees of motor and sensory loss; can walk with braces or may use a wheelchair, and can be relatively independent
3. May be at a higher risk for mobility, perfusion, and reflex activity complications
a. Cardiac arrhythmias and cardiac arrest
b. Deep vein thrombosis from peripheral vasodilation related to decreased muscle function
c. Orthostatic hypotension (especially above level of T7)
d. Autonomic hyperreflexia (possible only at or above the level of T6)
e. Sleep apnea
f. UTI and bladder dysfunction
g. Skin breakdown
h. Spasticity, contractures, and deformity
i. Difficult pain management related to dysesthetic or phantom pain
j. Depression, social isolation
B. Preadmission/preoperative interview and management
1. Provide a comfortable space for the interview.
2. Recognize that a physical disability alone does not affect intelligence.
a. Refer to the patient as a person with a disability not as a disabled person.
b. Speak directly to the patient.
c. Ask the patient the type of physical assistance he or she prefers.
3. Identify the level and duration of the disability.
4. Determine patient’s and family’s management and coping strategies.
5. Conduct interview and assessment per protocol.
a. Physical abilities, special needs
b. Use of assistive devices—braces, splints, ADL modifications
c. Willingness and ability of family to participate in preoperative preparation and postoperative care
6. Complete health history per protocol
a. Cardiac arrhythmias and cardiac arrest
(1) Electrolyte imbalance
(2) Response to vagal stimulation
b. Orthostatic hypotension—history of hypotension when the head of the bed is raised or when the patient is gotten out of bed
c. Autonomic hyperreflexia—previous response to noxious stimulation of the sensory receptors
(1) Urinary calculi, severe bladder infections, urinary retention or bladder distention/spasms
(2) Bowel impaction and stimulation of anal reflex
(3) Temperature changes
(4) Tight, irritating clothes
(5) Decubiti
(6) Pain and operative incisions
d. Pain
(1) Spinal cord injury pain most common type of pain in this population
(a) Mild, tingling to severe, intractable
(b) Usually unresponsive to standard pain treatments
(2) Transitional zone pain
(a) Felt at the level of injury
(b) Bandlike pattern over the trunk or upper arms
(3) Pain can be felt above or below the level of injury.
(4) Pain management techniques patient has found most helpful
e. Spasticity
(1) A state of increased tonus in a weak muscle
(2) Usually peaks 1.5 to 2 years after the injury
(3) Gradual regression
f. Pressure sores
(1) Usual skin care routine
(2) Positioning routine
g. Bladder and bowel management—recognize increased risk for latex sensitivity if indwelling catheter present.
h. Nutrition
(1) Type of diet
(2) Amount of assistance needed to eat
(3) Mechanical consistency of foods
(4) Methods used to prevent aspiration
7. Physical assessment per protocol
8. Psychosocial assessment per protocol
a. Anxiety
(1) Losing independence
(2) Suffering greater disability caused by complications from procedure
(3) Inadequate pain relief postoperatively
b. Support system
(1) Availability and willingness of responsible adult to provide care at home
(2) Arrangements for safe transport to and from the facility
(3) Referrals to social services if needed
(a) Make arrangements for additional equipment in the home.
(b) May need home health care for postoperative discharge care
9. Develop a plan of care based on the knowledge and needs of the patient and family.
10. Preoperative instructions per protocol—include family and caregiver if possible.
11. Complete preparation for admission.
a. Preoperative tests as ordered
b. Referrals as necessary
c. Document and communicate the patient’s special needs to the perioperative team members.
C. Admission (see Box 19-1)
1. Use latex precautions if the patient is on a bladder program or has indwelling catheter.
2. Laboratory values within acceptable range
a. Electrolytes, especially potassium
b. Blood coagulation studies
c. Urinalysis—evaluate for evidence of UTI
D. Preoperative holding and intraoperative (see Box 19-2)
1. Use latex precautions if necessary.
2. Maintain normothermia.
3. Be aware of potential for:
a. Cardiac arrhythmias
(1) Electrolytes, especially potassium within normal range
(2) Avoid excessive vagal stimulation.
b. Autonomic hyperreflexia symptoms
(1) Hypertension
(2) Superficial vasodilatation
(3) Flushing
(4) Profuse sweating
(5) Piloerection (gooseflesh) occurring above the level of injury, often seen in patients with upper thoracic and cervical injuries
c. Pain, paresthesia, and hyperesthesia
d. Spasticity
(1) May result from a slight touch on the skin
(2) Aggravated by cold or staying in one position for a prolonged period
4. Move patient with care, lifting rather than pulling.
5. Avoid pressure on bony prominences by positioning or use of padding.
E. Phase I (see Box 19-3)
1. Continue use of latex precautions if necessary.
2. Keep patient warm.
3. Be aware that even slight touch could trigger spasticity.
4. Monitor for signs of bladder distention.
5. Monitor for signs of autonomic hyperreflexia.
a. Paroxysmal hypertension
b. Pounding headache
c. Vasodilatation
d. Flushing
e. Profuse sweating
f. Piloerection
6. Increased potential for orthostatic hypotension exists.
a. Be cautious when elevating the head of the bed if caring for a patient with quadriplegia.
7. Be aggressive with pain management.
F. Phase II (see Box 19-4)
1. Keep patient warm without overheating.
2. Be aware that light touch on the skin may trigger spasticity.
3. Monitor for bladder distention.
4. Monitor for autonomic hyperreflexia.
5. Monitor for orthostatic hypotension.
a. Be cautious when elevating the head of the bed of the patient.
b. Provide assistance when increasing activity.
6. Be aggressive with pain management.
7. Return assistive devices as soon as possible.
G. Discharge (see Box 19-5)
VIII. TRAUMATIC BRAIN INJURY
A. Background information
1. Approximately 600,000 new traumatic brain injuries (TBIs) occur in the United States each year.
a. Nearly 100% of persons with severe head injury and two thirds of those with mild injury will be permanently disabled.
b. Greatest cause of TBI is motor vehicle accidents.
c. Most severe head injuries occur in adolescents and young adults.
2. May have motor impairment
a. Spasticity, tremors, ataxia
b. Weakness
c. Apraxia: the inability to perform a skilled motor act in the absence of paralysis
d. Paralysis
e. Poor breathing patterns
3. May have sensory impairment of:
a. Sense of position
b. Spatial judgment
c. Vision, hearing, touch, smell, and taste
d. Increased or decreased pain sensitivity
4. May have communication impairment
a. Aphasia: inability to communicate
b. Dysarthria: defective articulation caused by motor deficits of the tongue or muscles used for speech
5. May have cognitive impairment
a. Abstract thinking
b. Judgment
c. Generalization and planning abilities
d. Memory
e. Decreased concentration ability
f. Reduced tolerance for stress, irritability, impatience—labile emotions
B. Preadmission and preoperative interview and management
1. An in-person interview may be more beneficial than a telephone interview; the patient may use nonverbal forms of communication.
2. Provide a calm, quiet environment; limit stimulation factors.
3. Include family and caregiver whenever possible.
4. Allow adequate times for interview and assessment; recognize that the patient’s attention span may be limited.
5. Remember to include patient in the conversation.
6. Complete health history per protocol
a. Cause and duration of disability
b. Type of limitations caused by disability
c. Seizure activity, if appropriate
(1) Manifestation of seizure
(2) Frequency
(3) Aura, triggers
(4) Effective treatment
7. Assessment per protocol
a. Abilities, special needs
(1) Level reached on a rehabilitation scale
(a) Rancho Los Amigos, a cognitive functioning scale; Level I—no response, total assistance, to Level X—modified independent
(b) Disability Rating Scale—point system to estimate general level of disability from none to extreme vegetative state
(2) Patient’s and family’s or caregiver’s successful management techniques
b. Use of assistive devices
8. Physical assessment per protocol
a. Swallowing difficulty because of poor muscle control
b. Positioning problems caused by paralysis, contractures, spasticity
9. Psychosocial assessment
a. Anxiety
(1) Be alert to nonverbal communication.
(2) Level of ability to cope with hospital environment
b. Emotional lability
c. Support system
(1) Arrangements for safe transport to and from the facility
(2) Willingness and ability of family to participate in preoperative preparation and postoperative care
d. Make referrals as necessary.
10. Develop a plan of care based on the knowledge and needs of the patient and family.
11. Preoperative teaching per protocol
a. Provide verbal and written preoperative instructions.
b. Include family and caregiver in instructions if at all possible.
c. Adjust teaching to patient’s level of disability.
(1) Recognize patient may have short attention span.
(2) Patient may have short-term memory problems.
(3) Use short, clear instructions; do not use abstract ideas.
d. Emphasize pain management.
(1) Determine which pain scale is most appropriate for the patient.
(2) After instruction, have patient demonstrate the use of the pain scale.
12. Complete preparation for admission.
a. Preoperative tests as ordered
b. Referrals as needed
c. Document and communicate special needs to the perioperative team members.
C. Admission (see Box 19-1)
1. Limit stimulation in room.
D. Preoperative holding and intraoperative (see Box 19-2)
1. Recognize that the patient may be emotionally labile.
2. Provide a calm, quiet environment.
E. Phase I (see Box 19-3)
1. If swallowing difficulty exists, minimize risk for aspiration.
a. Observe for return of swallowing and gag reflexes.
b. Suction as needed.
c. Elevate the head of the bed if allowed.
d. Position on side if not contraindicated.
2. Allow use of assistive devices as soon as possible.
F. Phase II (see Box 19-4)
1. Verify competent adult help at home after discharge.
G. Postdischarge (see Box 19-5)
IX. PARKINSON’S DISEASE (see Chapter 17)
A. Background information
1. Parkinson’s disease (PD) is a common, slowly progressive neurological disease.
a. Peak onset at age 55 to 60
b. Affects men more than women: 55 men to 45 women
c. Affects Hispanics/Latinos and Non-Hispanic Whites more than African Americans
d. Progresses from diagnosis to major disability over 10 to 20 years
2. Symptoms result primarily from loss of dopamine in the brain.
3. Primary clinical symptoms
a. Rigidity of the limbs—appreciated as stiffness of the joints simulating arthritis
b. Tremor of the limbs—more prominent in the hands and is asymmetrical, often occurring while at rest
c. Bradykinesia of the limbs and body—most prominent and disabling symptom of PD
(1) Difficulty initiating movement
(2) Slowness in movement
(3) Paucity or incompleteness of movement
d. Postural instability—results from impairment of postural reflexes
(1) Patient perceives as unsteadiness or lack of balance.
(2) When patients trip, they are unable to stop falling or ease their fall.
4. Secondary symptoms
a. Difficulty walking resulting from a combination of bradykinesia and postural instability
(1) Short steps and shuffling gait
(2) Festinating gait—a manner of walking in which speed increases to catch up with a displaced center of gravity
(3) Anteropulsion—be propelled forward, or backward (retropulsion)
(4) Freeze—a difficulty turning, and a tendency to stop abruptly and inexplicably
(5) Stooped posture
b. Masklike features
(1) Diminished facial expression
(2) Stares straight ahead
(3) Has decreased blinking of eyes
c. Speech changes
(1) Difficulty initiating speech
(2) Difficulty coordinating expiration and articulation
d. Autonomic symptoms
(1) Drooling
(2) Excessive perspiration
(3) Constipation
(4) Orthostatic hypotension
(5) Dysphasia
e. Changes in behavior and mental ability
(1) Depression
(2) Slowness of information processing
(3) Social withdrawal
(4) Generalized apathy and loss of appetite
(5) Dementia—occurs in 15% of patients with PD as they age
f. General weakness and muscle fatigue
(1) Complications can include injuries from falls, skin breakdown, UTIs, aspiration pneumonia.
g. Hypersensitivity to heat
(1) Treatment
h. Antiparkinson drugs to restore dopamine or mimic dopamine’s actions; partial list
(1) Antiparkinson: levodopa (Larodopa), carbidopa-levodopa (Sinement)
(2) Dopamine agonists: pergolide (Permax), pramipexole (Mirapex), ropinirole (Requip)
(3) Antivirals: amantadine
(4) Anticholinergics: benztropine mesylate (Cogentin) and trihexyphenidyl (Artane)
i. Surgical treatment
(1) Thalamotomy, pallidotomy
(2) Deep brain stimulation
B. Preadmission and preoperative interview and management
1. An in-person interview affords the opportunity to observe the patient’s abilities and interaction with family members.
2. Maintain a calm, unhurried, accepting attitude in a safe, comfortable environment.
a. Provide assistance with ambulation.
b. Recognize that information processing may be slowed.
3. Speak to the patient and encourage to respond in whatever manner he or she can.
a. PD does not affect patient’s intelligence.
b. Respect patient’s level of independence.
4. Include the family and caregiver in preoperative preparation when possible.
5. Assessment per protocol
a. Abilities and special needs of the patient
(1) Determine the patient’s and/or family’s understanding of PD.
(2) Length of time disease has been present
(3) Manifestations of PD
(4) Effects of PD on patient
(a) Patient’s usual routine to cope with limitations
(b) Consider using ADL scoring system for PD.
(c) Patient’s and family’s successful management techniques
(5) Use of assistive devices
(6) Sleep disturbances
b. Willingness and ability of family and caregiver to participate in preoperative preparation and postoperative care
6. Complete health history per protocol
7. Physical assessment per protocol
a. Vital signs and oxygen saturation
b. Muscle strength
c. Location of tremors
d. History of dysphagia
8. Cognitive assessment
a. Memory loss
b. Depression
c. Information processing speed may be slowed down.
9. Psychosocial assessment per protocol
a. Anxiety
(1) Prominent feature in 40% of PD patients
(2) Many PD patients have panic attacks.
(3) Determine patient’s coping mechanisms.
b. Support system
(1) Competent adult help at home after discharge
(2) Arrangements made for safe transportation to and from the hospital
10. Develop plan of care based on the patient’s and family’s knowledge and needs.
11. Preoperative teaching per protocol
a. Provide verbal and written preoperative instructions.
b. Patients should be instructed to take normal PD medications the day of surgery.
(1) Prevent muscle weakness and tremors that make self-care difficult.
(2) Rigidity may contribute to a difficult intubation.
(3) Rigidity predisposes to venous thrombosis.
12. Complete preparation for admission per protocol.
a. Referrals as necessary
(1) May require physical therapy and occupational therapy to maintain function postoperatively
b. Preoperative testing as ordered
c. Document and communicate patient’s special needs to the perianesthesia team.
C. Admission (see Box 19-1)
1. Verify competent adult help at home after discharge.
2. Physical assessment per protocol
a. Muscle strength
b. Tremors, rigidity
c. Swallowing problems
3. Prepare patient per protocol.
a. Verify PD drugs have been taken as instructed.
b. Drugs that exacerbate extrapyramidal symptoms should be avoided.
(1) Metoclopramide
(2) Droperidol
(3) Phenothiazines
(4) Alcohol
4. Provide emotional support for family and patient.
a. Use measures to decrease anxiety.
b. Provide safe environment.
(1) Assist patient in getting out of bed.
(2) Keep side rails up and bed position low.
(3) Do not leave patient unattended.
c. Maintain comfortable temperature.
D. Preoperative holding and intraoperative (see Box 19-2)
1. Recognize potential for aspiration.
2. Avoid overheating.
3. Recognize patient is at greater risk for hypotension and cardiac arrhythmias.
E. Phase I (see Box 19-3)
1. Increased risk for aspiration because of difficult or ineffective swallowing
a. Elevate head of the bed if allowed.
b. Suction as necessary.
c. Observe for return of gag and swallowing reflexes.
d. Position on side if not contraindicated.
2. Prevent overheating.
F. Phase II (see Box 19-4)
1. Increased risk for aspiration because of difficult or ineffective swallowing
a. Elevate head of the bed if allowed.
b. Suction as necessary.
c. Observe for return of gag and swallowing reflexes.
d. Position on side if not contraindicated.
2. Prevent overheating.
3. Increased risk of orthostatic hypotension
a. Ambulate gradually and with assistance.
b. Evaluate vital signs after activity progression.
G. Postdischarge (see Box 19-5)
X. MULTIPLE SCLEROSIS (see Chapter 17)
A. Background information
1. Multiple sclerosis (MS): a chronic, unpredictable neurological disease that affects the white matter of the brain and the spinal cord.
2. Myelin is lost in multiple areas, leaving scar tissue—sclerosis.
a. Damaged areas—plaques or lesions
b. Disrupts ability of the nerves to conduct electrical impulses to and from the brain
3. Usually diagnosed between the ages of 20 and 50
4. Each year, 25,000 new cases diagnosed
5. Two to three times as many women as men have MS.
6. Clinical courses—each may be mild, moderate, or severe.
a. Benign MS—affects 20% of patients; causes mild disability with infrequent, mild, and early attacks followed by near-complete recovery
b. Exacerbating-remitting MS—affects 25% of patients with frequent attacks that start early in the course of the illness, followed by less-than-complete clearing of signs and symptoms than in benign MS
c. Chronic relapsing MS—affects approximately 40% of patients; has fewer, less-complete remissions after an exacerbation than has exacerbating-remitting MS. Chronic relapsing MS has a cumulative progression, with more symptoms occurring during each new attack.
d. Chronic progressive MS—affects approximately 15% of patients and is similar to chronic relapsing MS except that the onset is more subtle and the disease progresses slowly without remission
7. Symptoms are unpredictable; vary from person to person and from time to time in the same person.
a. Sensory—numbness, paresthesia, pain, dysesthesia, trigeminal neuralgia, Lhermitte’s sign, chronic pain from other symptoms, decreased proprioception and sense of temperature, depth, and vibration
b. Motor—paresis, paralysis, dragging of foot, dysphagia, spasticity, diplopia, bowel and bladder dysfunction (incontinence or retention)
c. Cerebellar—ataxia, staggering, loss of balance and coordination, nystagmus, speech disturbances, tremors, vertigo
d. Other symptoms—optic neuritis, impotence or decreased genital sensation, depression or euphoria, fatigue or decreased energy level
8. Factors that may cause a relapse
a. Infections
b. Trauma—accidental or planned (i.e., surgery)
c. Pregnancy
d. Undue fatigue or excessive exertion
e. Overheating or excessive chilling or cold
f. Emotional stress
9. Treatment
a. Immunomodulators—beta-interferon (Avonex) and glatiramer (Copaxone)
b. Monoclonal antibodies—natalizumab (Antegren)
c. Steroids given to decrease inflammation and increase periods of remission
d. Antispasmodics—baclofen (Lioresal) and dantrolene (Dantrium)
e. Fatigue controlled with amantadine (Symmetrel)
B. Preadmission and preoperative interview and management
1. Provide a comfortable, safe environment.
a. Allow adequate time—patient fatigue may be a factor.
b. May need extra time to formulate questions and responses
2. Assessment per protocol
a. Abilities, special needs
(1) Determine level and duration of disease.
(2) Determine patient’s and family’s understanding of MS.
(3) Determine patient’s and family’s routine to minimize symptoms.
b. Use of assistive devices
c. Willingness and capability of family to participate in preoperative preparations and postoperative care
3. Complete health history per protocol
a. Identify previous events triggering relapses.
b. Determine patient’s response to physical and psychological stresses.
4. Physical assessment per protocol
a. Evaluate ability to swallow.
b. Evidence of infectious process present
5. Psychosocial assessment per protocol
a. Anxiety
(1) Surgery may cause relapse.
(2) Loss of independence
b. Support system
(1) Competent adult help at home on discharge
(2) Arrangements made for safe transport to and from the hospital
6. Develop plan of care based on patient’s and family’s knowledge and needs.
7. Preoperative teaching per protocol
a. Provide verbal and written instructions.
b. Include family in instructions if at all possible.
8. Complete preparation for admission per protocol.
a. Make referrals as necessary.
b. Preoperative tests as ordered
c. Document and communicate special needs to the perianesthesia team.
C. Admission (see Box 19-1)
1. Provide comfortable, safe environment.
a. Assist patient in getting out of bed if needed.
b. Keep side rails up and bed in low position.
2. Use measures to reduce stress.
a. Explain what will be happening.
b. Allow patient to verbalize concerns.
c. Allow family to be with patient as long as possible.
d. Allow use of assistive devices as long as possible.
e. Allow extra time for patient to answer or formulate questions.
3. Avoid undue fatigue; provide periods of rest.
4. Physical assessment per routine protocol
a. Sensory deficit
b. Motor deficit
c. Cerebellar disturbances
D. Preoperative holding and intraoperative (see Box 19-2)
1. Maintain normothermia.
2. If swallowing deficits, may be at increased risk for aspiration
a. Elevate head of bed if possible.
b. Suction as needed.
c. When possible, position on side.
E. Phase I (see Box 19-3)
1. Provide specialized care based on patient’s symptoms.
2. May be at higher risk for aspiration
a. Elevate head of bed if not contraindicated.
b. Suction as needed.
c. Observe for return of swallowing and gag reflexes.
d. Position on side if not contraindicated.
3. Maintain normothermia.
4. Reduce stress.
a. Reorient patient to surroundings.
b. Medicate for pain or anxiety as necessary.
F. Phase II (see Box 19-4)
1. May be at increased risk for aspiration
a. Elevate head of bed if not contraindicated.
b. Suction as needed.
c. Observe for return of swallowing and gag reflexes.
d. Position on side if not contraindicated.
2. Provide comfortable, safe environment.
a. Reorient patient to surroundings.
b. Allow use of assistive devices as soon as possible.
c. Assist patient with ambulation.
3. Reduce stress.
a. Reunite patient and family as soon as possible.
b. Avoid fatigue; provide periods of rest.
G. Postdischarge (see Box 19-5)
XI. MYASTHENIA GRAVIS (see Chapter 17)
A. Background information
1. Myasthenia gravis (MG): a chronic, progressive autoimmune disease causing voluntary muscle weakness.
2. Two thirds of patients first present with oculomotor disturbances, ptosis, or diplopia.
3. Most other patients first have oropharyngeal muscle weakness, difficulty chewing, swallowing, or talking.
4. Severity of weakness fluctuates, being the most severe after prolonged use of affected muscles.
5. As progression occurs, the patient may exhibit:
a. Increased weakness of certain voluntary muscles
b. Improvement of muscle strength with rest
c. Dramatic improvement in muscle strength with use of anticholinesterase drugs
d. Difficulty with speech
e. Difficulty swallowing
f. Respiratory insufficiency
g. Drooping head
h. Fatigue
i. Bowel and bladder dysfunction
j. Depression
k. May develop myasthenia crisis (weakness from MG exacerbation) or a cholinergic crisis (weakness from too much anticholinesterase medication)
(1) Acute respiratory difficulty
(2) Acute motor weakness of voluntary muscles, including those for swallowing, speaking, and moving parts of the body
(3) Treatment for either crisis is respiratory assistance.
6. Symptoms worsen with:
a. Emotional upset
b. Systemic illness
c. Viral respiratory infections
d. Hypothyroidism and hyperthyroidism
e. Pregnancy, menstrual cycle
f. Drugs affecting neuromuscular transmission
g. Increased body temperature
B. Preadmission and preoperative interview and management
1. Provide a calm environment.
2. Allow for periods of rest if necessary.
3. Include family in preoperative preparations whenever possible.
4. If patient has difficulty talking, provide with alternative communication tools.
5. Assessment per protocol
a. Patient’s abilities and special needs
(1) Determine patient’s and family’s understanding of MG.
(2) Patient’s successful management techniques
(3) Use of assistive devices
(4) If patient has had any myasthenia crisis episodes—treatment needed.
b. Willingness and capability of family to participate in preoperative preparation and postoperative care
6. Complete health history per protocol
a. Progression of disease
b. Normal routine to avoid exacerbating factors
c. Particularly note anticholinesterase medications patient is taking for MG.
(1) Pyridostigmine (Mestinon)
(2) Neostigmine (Prostigmin)
(3) Cholinergic effects can be reversed by common perioperative medications such as mycin-type antibiotics, aminoglycosides, nondepolarizing muscle relaxants, morphine, procainamide.
7. Physical assessment per protocol
a. Respiratory assessment—ease of breathing, depth of respirations, auscultation
b. Muscle strength—identify which muscles are involved with the disease.
8. Psychosocial assessment per protocol
a. Anxiety
(1) Determine patient’s coping mechanisms.
(2) Fear of respiratory difficulties during surgery and recovery
b. Support system
9. Develop a plan of care based on patient’s and family’s knowledge and needs.
10. Preoperative teaching per protocol
11. Complete preparation for admission per protocol.
a. Referrals as necessary
b. Preoperative tests as ordered
c. Document and communicate patient’s special needs to the perianesthesia team.
C. Admission (see Box 19-1)
1. Physical assessment per protocol
a. Respiratory function assessment
(1) Auscultation
(2) Observation
b. Muscle strength—note which muscles are affected by the disease at this time.
2. Monitor patient closely after any medication for signs of interaction with routine MS medications.
a. Increased muscle weakness
b. Decreased respirations
c. Agitation
D. Preoperative holding and intraoperative (see Box 19-2)
1. Observe for myasthenia crisis, manifested with:
a. Increased muscle weakness
b. Respiratory distress
c. Difficulty talking or swallowing
2. Potential for aspiration
a. Elevate head of bed if possible.
b. Suction as necessary.
c. Monitor for swallowing difficulty.
3. At increased risk for infection
a. Maintain aseptic technique.
b. Use care to avoid skin tears.
(1) Protect bony prominences by positioning and padding.
(2) Use care when removing adhesive pads.
(3) Lift rather than pull when moving patient.
4. Maintain normothermia.
5. Use measures to reduce stress.
6. Monitor closely after any medication for signs of interaction with routine MG medications.
a. Increased muscle weakness
b. Respiratory difficulty
c. Agitation
7. Protect eyes from injury.
a. Lubricant
b. Tape eyelids closed.
E. Phase I (see Box 19-3)
1. Greater risk for aspiration
a. Observe for return of gag and swallowing reflexes.
b. Elevate head of bed if allowed.
c. Suction as necessary.
d. Watch for weakness in throat.
(1) Difficulty speaking
(2) Difficulty swallowing
e. Position on side if not contraindicated.
2. Greater risk for respiratory distress
a. Auscultation of lungs
b. Observe respiratory pattern and effort.
c. Monitor oxygen saturation.
3. Risk for myasthenia crisis
a. Maintain normothermia.
b. Monitor patient closely after any medication for signs of interaction with routine MG medications.
(1) Increased muscle weakness
(2) Respiratory difficulty
(3) Agitation
c. Observe for symptoms that may indicate crisis.
(1) Acute respiratory distress
(2) Acute motor weakness of voluntary muscles, including those for swallowing, speaking, and moving parts of the body
d. Assess muscle strength frequently.
4. Monitor vital signs and temperature frequently.
F. Phase II (see Box 19-4)
1. Risk for respiratory distress
a. Auscultate lungs.
b. Observe respiratory pattern and effort.
c. Monitor oxygen saturation.
d. Avoid fatigue.
2. Higher risk for aspiration
a. Elevate head of bed.
b. Suction as necessary.
c. Assess for weakness of throat muscles.
d. Position on side if not contraindicated.
e. Exercise caution when giving fluids or solids.
3. Risk for myasthenia crisis—observe for symptoms that may indicate an impending myasthenia crisis.
a. Acute respiratory distress
b. Acute motor weakness of voluntary muscles, including those used for swallowing, speaking, and moving parts of the body
4. Monitor patient closely after any medication for signs of interaction with routine MG medications.
a. Increased muscle weakness
b. Respiratory difficulty
c. Agitation
5. Assess muscle strength frequently.
6. Reduce psychological stress.
a. Reorient patient to surroundings.
b. Allow use of assistive devices as soon as possible.
c. Allow family to be with patient as soon as possible.
7. Keep patient comfortable.
a. Have room at comfortable temperature—prevent overheating the patient.
b. Medicate for pain or nausea and observe for desired or adverse medication reactions.
c. Provide nourishment with care.
d. Check for bladder distention.
G. Postdischarge (see Box 19-5)
XII. AUTISM SPECTRUM AND INTELLECTUAL DISORDERS IN THE PEDIATRIC PATIENT (see Chapter 11)
A. Autism spectrum disorders
1. Cause: unknown but thought to be a result of an interaction between genes and the environment
2. Incidence: mean prevalence is 6.6 per 1000 children.
3. Symptoms: involve three types of behaviors
a. Impaired speech
b. Problems interacting socially
c. Tendency towards repetitive behavior and interests
4. Disorders include:
a. Autism
(1) Symptoms include:
(a) Persistence of unusual reflexes
(b) High rates of seizure disorders (25% in most cases)
(c) Marked problems in social interaction
(d) Delayed and deviant communication development
(e) Other behaviors:
(i) Stereotyped motor behaviors (hand flapping, body rocking)
(ii) Insistence on sameness
(iii) Resistance to change
b. Asperger’s syndrome
(1) Symptoms include:
(a) Deficits in social interaction and unusual responses to the environment
(b) Cognitive and communicative development within the normal or near-normal range in the first years of life
(c) Fewer deficits noted in terms of verbal skills compared to other autism spectrum disorders
c. Childhood disintegrative disorder
(1) Symptoms resemble autism but only after a relatively prolonged period (usually 2-4 years) of clearly normal development; differs from autism in the pattern of onset, course, and outcome.
(2) May mimic childhood schizophrenia
d. Rett’s disorder
(1) Affects girls almost exclusively
(2) Symptoms follow normal early development:
(a) The first few months of life: head growth begins to decelerate with a loss of purposeful hand movements and striking motor involvement.
(b) Profound mental retardation is typical.
e. Pervasive developmental disorder
(1) Also referred to as “atypical personality development” or “atypical autism”
(2) Encompasses cases where there is marked impairment of social interaction, communication, and/or stereotyped behavior patterns or interest
(3) Full features of autism are not met.
f. Intellectual disability
(1) Symptoms include significantly subaverage general intellectual functioning manifested before 18 years of age.
(2) Limited adaptive skills in at least two or more areas of functioning:
(a) Communication
(b) Self-care, home living
(c) Use of community resources
(d) Social/interpersonal skills
(e) Self-direction
(f) Functional academic skills
(g) Health and safety
(h) Work
(i) Leisure
(3) Degrees of severity
(a) Mild mental retardation (most common)
(i) Often not noticed by observers
(ii) May note developmental delays (achievement of developmental milestones later than expected) in language acquisition, social development, and motor skills
(iii) Can acquire these skills to the third- to sixth-grade level, and can be guided toward social appropriateness
(b) Moderate mental retardation
(i) Obvious delays in motor development and speech
(ii) Can learn basic self-help activities
(iii) Seldom progress academically beyond the second-grade level
(c) Severe mental retardation
(i) Typically acquire little if any communicative speech during preschool years
(ii) Education focuses on the basics of independent living skills, such as toileting, bathing, simple communication, self-feeding, and rules of behavior.
B. Perianesthesia considerations
1. When speaking to the child: speak clearly, simply, and slowly.
a. Allow ample time for the child to process information.
b. Do not insist on eye contact—some children with autistic tendencies find eye contact distressing.
c. Provide for language tools as required by the child including communication boards and sign language.
2. Obtain information from the caregivers about the child’s routines, likes, dislikes, rituals, skills and abilities regarding self-care, such as feeding, dressing, bathing, and toileting.
3. Assessment should also include the child’s communication skills, interactive patterns, and response to others.
4. Assess the method the caregivers use to give the child medications.
5. Assess family’s support system.
6. Determine utilization of nontraditional alternative treatments, which may or may not impact care.
a. Several nutritional supplements have been used such as high-dose pyridoxine (vitamin B 6), magnesium, and ascorbic acid (vitamin C).
b. Dietary requirements including certain foods that have been eliminated from the diet such as gluten (e.g., wheat and barley) and casein (found in milk) products
7. Arrange for continuity of care settings and care providers whenever possible.
XIII PEDIATRIC MOTOR/NEUROLOGICAL DISABILITIES (see Chapter 11)
A. Cerebral palsy
1. Chronic motor dysfunction caused by damage to the motor areas of the brain before, during, or after birth
a. Alterations in muscle tone such as abnormal posturing and movements
b. Delay in gross motor skills (i.e., sitting, crawling, cruising, or walking)
c. Fine motor coordination may be affected, hampering the ability to perform ADLs including self-feeding and dressing.
d. Many infants and children have other deficits (i.e., poor vision, strabismus or nystagmus, hearing loss, cognitive impairments, speech or language delays, seizures, and growth problems).
2. Incidence is estimated to be 7 per 1000 live births per year.
3. Many have additional cognitive and language delays ranging from mild to severe.
B. Down syndrome
1. Congenital chromosomal disorder characterized by varied degrees of mental retardation and a characteristic appearance
a. Common features of Down syndrome include:
(1) Muscle weakness and hypotonia
(2) Oblique palpebral fissures and an upward slant to the eyes
(3) A small nose and a depressed nasal bridge
(4) A large tongue in a small mouth
(5) A high-arched palate
(6) Square hands with short fifth finger, and a simian (single transverse) crease across the palm of the hand
(7) A wide space between the great and second toe
(8) Epicanthic folds (small skin folds at the inner corners of the eyes)
2. Incidence for women older than 30 years is 1 in 1500; in women older than 40 it increases to 1 in 100 live births.
3. Associated conditions include congenital heart defects (especially septal defects), respiratory tract infections and chronic otitis media, altered immune system, gastrointestinal conditions (Hirschsprung’s megacolon, tracheoesophageal fistula), hypothyroidism, ocular cataract, leukemia.
C. Spina bifida (SB)
1. Neural tube defect where there is an incomplete closure of the vertebrae and neural tube
a. Saclike protrusion on the neonate’s back noted at birth
b. Clinical manifestations depend on the location of the lesion—the higher the deformity, the more neurological deficits will be present.
(1) Lower extremities may be partially or completely paralyzed.
(2) Bowel and bladder may or may not be affected.
(3) Renal impairment may occur secondary to faulty kidney innervation.
(4) Orthopedic complications such as flexion or extension contractures, talipes valgus, or varus contractures may also be present at birth.
(5) Approximately 90% of infants with the most severe form of SB also develop hydrocephalus.
2. Incidence is approximately 1 in every 2000 births in the United States each year; higher in families with Hispanic or white European ancestries.
3. Complications associated with the defect include:
a. UTIs
b. Orthopedic problems such as kyphosis, scoliosis, tethering of the spinal cord
c. Back pain
d. Spasticity
e. Skin breakdown.
f. Loss of sensation secondary to interrupted nerve pathways
D. Perianesthesia considerations
1. Obtain information from the caregivers about the child’s routines, likes, dislikes, rituals, skills and abilities regarding self-care, such as feeding, dressing, bathing, and toileting.
2. Assessment should also include the child’s communication skills, interactive patterns, and response to others.
3. Assess the method the caregivers use to give the child medications.
4. Assess family’s support system.
5. Determine utilization of nontraditional alternative treatments, which may or may not impact care.
6. Ensure the infant’s or child’s body is in the best possible alignment, using pillows and bolsters as supports.
7. Special care should be taken to protect bony prominences because they are prone to breakdown.
8. Postoperatively, monitor carefully for aspiration, cardiac abnormalities, and respiratory complications due to congenital anomalies associated with physical disabilities.
9. If the infant or child is hospitalized, the at-home regime should be followed as much as possible, and physical, occupational, and speech therapy department referrals should be made so that therapy sessions can be initiated.
10. Infants, children, and adolescents with SB are 41% more likely to have latex allergy than the general public.
a. Signs and symptoms
(1) Urticaria
(2) Wheezing
(3) Watery eyes
(4) Rash
(5) Anaphylaxis, in extreme cases
b. Ensure equipment such as tourniquets, intravenous tubing, urinary and intravenous catheters, and tapes are latex free.
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