NURS 6531: Primary Care of Adults Across the Lifespan | Week 10

In the United States, stroke is the fourth leading cause of death and a leading cause of adult disability (National Stroke Association, 2012). Of all stroke cases, 20% are recurrent strokes in patients (American Heart Association, 2012). This outlines the importance of patient education for stroke prevention and disorder management. Depending on the patient’s medical history, stroke prevention might be as simple as recommendations for changes in behavior and lifestyle. This was the case for Connie Bentley, an avid weightlifter. She exercised often and was healthy, but her blood pressure always rose when she lifted weights, which eventually caused her to suffer a stroke. After receiving treatment for her stroke, Bentley’s provider recommended that she stop lifting weights, as it would increase her risk of recurrent stroke. Instead, her provider suggested alternative activities such as tai chi, swimming, and hiking (Bentley, 2012). Although this change was difficult for Bentley, she understood the risks because of provider-patient collaboration and education. When developing treatment and management plans that include behavior and lifestyle changes, provider-patient collaboration is essential, as this will increase the likelihood of patient adherence to established plans.

This week, as you explore neurologic disorders, you examine stroke prevention methods for select patient populations.

Learning Objectives

By the end of this week, students will:

• Assess differential diagnoses for patients with neurological disorders
• Analyze the role of patient information in differential diagnosis for neurological disorders
• Evaluate the patient treatment options for neurological disorders
• Understand and apply key terms, concepts, and principles related to neurological disorders
• Analyze pattern recognition in patient diagnoses

Learning Resources

Required Readings

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice (5th ed.). St. Louis, MO: Elsevier.

• • Part 19, “Evaluation and Management of Multisystem Disorders”

• • • Chapter 227, “Sleep Disorders” (pp. 1209-1217)

This chapter differentiates between normal sleep from abnormal sleep and identifies the epidemiology, clinical presentation, and management of sleep disorders.

• •  
  • Part 16, “Evaluation and Management of Neurologic Disorders” (pp. 999-1070)

This part explores the evaluation process of neurologic disorders. It then covers the pathophysiology, clinical presentation, diagnostic criteria, and complications of neurologic disorders.

Lawrence, M., Fraser, H., Woods, C., & McCall, J. (2011). Secondary prevention of stroke and transient ischemic attack. Nursing Standard, 26(9), 41–46.

This article examines risk factors for stroke and explores prevention methods for patients at high risk of suffering from strokes.

Lawrence, M., Kerr, S., Watson, H. E., Jackson, J., & Brownlee, M. G. (2009). A summary of the guidance relating to four lifestyle risk factors for recurrent stroke. British Journal of Neuroscience Nursing, 5(10), 471–476.

This article explores lifestyle and behavioral risk factors for stroke. It also describes the role of nurses in educating patients about stroke prevention.

Perry, M. (2012). Stroke prevention. Practice Nurse, 42(8), 14–18.

This article identifies patient risk factors for strokes. It also explores patient prevention and education methods to lower the prevalence of the disorder.

National Institute of Health. (n.d.). National institute of neurological disorders and stroke. Retrieved November 1, 2012, from http://www.ninds.nih.gov/index.htm

This website provides information about neurological disorders and strokes, as well as potential causes, prevention strategies, diagnosis, and treatment of these disorders.

Discussion: Diagnosing Neurological Disorders

As an advanced practice nurse, you will likely observe patients who experience neurological disorders. Challenging to the diagnosis of neurological disorders is the realization that many manifestations of disease may not be overt physically.

For this Discussion, consider the following three case studies of patients presenting with neurological disorders.

Case Study 1

80-year-old male Caucasian male brought to the clinic by his wife concerned about his “memory problems”. Per the wife, she has noticed his memory declining but has never interfered with his daily activities until now. He is unable to remember his appointments and heavily relies on written notes for reminder. Just last week, he got lost driving and was not found by his family until 8 hours later. He is unable to use his cell phone or recall his home address or phone number. He has become a “hermit” per his wife. He has withdrawn from participating with church activities and has become less attentive.

PMH: HTN, controlled
Prostate cancer 20 years ago
Dyslipidemia
SH: no alcohol or tobacco use; needs assistance with medications
PE: VS stable, physical exam unremarkable

Case Study 2

A 30-year-old Asian female presents to the clinic with headaches. History of headaches since her teen years. Headaches have become more debilitating recently. Describes the pain as sharp, worsens with light and accompanied by nausea and at times vomiting. Rates the pain as 7/10. Typically takes 2 tabs of OTC Motrin with ‘some help’. “Sleeping it off in a darkened room’ helps alleviate the headache. VS WNL, physical exam unremarkable.

Case Study 3: A 50-year-old African American male presents with complaints of dizziness left arm weakness and fatigue. PMH: poorly controlled diabetes, hypertension, hyperlipidemia
PE: Upon exam, you noted a very mild dysarthria, he understands and follows commands very well. Mild weakness on the left side of the face is noted, and left sided homonymous hemianopsia but no ptosis or nystagmus or uvula deviation.

To Prepare:

• You will either select or be assigned one of the three case studies provided.
• Reflect on the provided patient information including history and physical exams.
• Think about a differential diagnosis. Consider the role the patient history and physical exam played in your diagnosis.
• Reflect on potential treatment options based on your diagnosis.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

By Day 3

Post an explanation of the primary diagnosis, as well as 3 differential diagnoses, for the patient in the case study that you selected or were assigned. Describe the role of the patient history and physical exam played in the diagnosis. Then, suggest potential treatment options based on your patient diagnosis.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days who selected or were assigned a different case study than you did. Respond to questions posed to you during the week.

ADDITIONAL INFORMATION;

Discuss dizziness, weakness and fatigue in elderly patients

Introduction

Dizziness is a common complaint in the elderly, and it can be a symptom of more serious disorders. In this article we will discuss some of the most common causes of dizziness seen in older adults, including:

Introduction

Dizziness, weakness and fatigue are common symptoms in the elderly. It is important to take a detailed history of these symptoms. The following questions should be asked:

• What is your main complaint?

• Has anything happened to you recently that might have caused this?

• Have other family members been affected by the same condition?

If there is an association with cardiovascular disease or stroke, ask about heart rate and blood pressure measurements before making any treatment decisions.

Differential diagnosis

If you suspect that your patient has dizziness, weakness or fatigue, a thorough history and physical examination are needed to make the correct diagnosis. Dizziness may be caused by a number of conditions ranging from ear infections to high blood pressure. Weakness can also result from diseases such as myasthenia gravis or multiple sclerosis (MS). Fatigue can stem from many factors including poor diet, lack of sleep and heavy lifting.

The importance of taking a history

The importance of taking a history is that it gives you the doctor a better understanding of your symptoms. If you are experiencing dizziness or weakness and fatigue, it is important to tell your doctor about these problems.

It’s also important for family members and carers to take part in this process as well because they may be able to help identify any underlying causes that may be contributing towards their loved one’s health issues.

Practical tips to assess patients complaining of dizziness

• Ask the patient to describe their symptoms.

• Ask the patient to describe what they do when they feel dizzy.

• Ask the patient if there are any other symptoms that may be associated with their dizziness, such as nausea and vomiting, diarrhea or constipation, palpitations and shortness of breath.

Ask the patient if there are any other symptoms that may be associated with their dizziness, such as nausea and vomiting, diarrhea or constipation, palpitations and shortness of breath. Ask the patient if they have any history of heart disease or high blood pressure.

Specific causes of dizziness common to the elderly

• Benign paroxysmal positional vertigo (BPPV) is a common cause of dizziness in the elderly.

• Peripheral vestibular disease refers to damage to the inner ear that causes symptoms such as tinnitus, hearing loss and vertigo.

• Labyrinthitis is inflammation of one or more parts of the labyrinth; it may be caused by an injury or infection. In some cases, it can lead to permanent damage if left untreated.

• Perilymphatic fistula occurs when there’s an opening between two parts of your body that normally don’t connect (the perilymphatic space). This can happen when fluid leaks into this space from another part of your body through an abnormal connection called a fistula tract.[1]

General classification of dizziness

Dizziness is a symptom that can be difficult to diagnose and verify. Symptoms are subjective, and it’s easy for patients to mistake them for other conditions. For example, dizziness may be mistaken for vertigo (sense of spinning) or motion sickness.

Dizziness is a common symptom in the elderly population as they age; however, it’s not necessarily always due to an underlying condition or disease process. Instead of trying to determine what exactly causes your dizziness by ruling out all other possible causes first (which will likely come down to finding out if someone has any underlying health issues), simply treating the symptoms may be enough on its own—and nothing more than that!

Encourage elderly patients with complaints to attend follow-up appointments.

Patients with symptoms of dizziness, weakness and fatigue should attend follow-up appointments.

• The frequency of follow-up visits will depend on the severity of the symptoms. For example, a patient who feels dizzy every day may need to return for a check-up every month or so; someone who has been feeling sickly all week might require an early morning appointment before work each week.

• You can remind elderly patients about their upcoming appointments by sending them an email reminder or phone call with the date written down on it (if they don’t have an appointment yet). If you’re unsure if your patient understands what needs doing at these visits or even why they’re important at all you should also ask them directly!

Conclusion

We have reviewed the most common causes of dizziness in the elderly. The main causes are:

• Loss of balance due to a change in gait or walking pattern,

• Dehydration and unbalanced electrolyte levels,

• Medication side effects such as sedatives and antidepressants, and lastly,

• Abnormal blood perfusion due to atherosclerosis or vascular damage caused by hypertension (which is usually treated with beta-blockers). In addition there may be other less common causes such as diabetes mellitus which affects both eyes; anemia caused by chronic inflammation of the retinal vessels behind each eye; thickening of the arteries near the optic nerve resulting from high blood pressure (HTN); disease of one or both carotid arteries that may cause intermittent symptoms such as loss of vision or sudden death because their blood supply has been compromised by plaque build-up within these vital organs; or increased activity level leading to undetected exhaustion (such as driving long distances at night without adequate rest breaks every couple hours).