Nursing Management CHRONIC NEUROLOGIC PROBLEMS

1
Nursing ManagementCHRONIC NEUROLOGIC PROBLEMS
2
Compare and contrast tension-type, migraine, and
cluster headaches in terms of etiology, clinical
manifestations, and collaborative care and
nursing management

• Tension-type
• Etiology
• ? pain sensitivity
• Muscle factors
• Clinical manifestations
• No prodrome
• Pain bilateral---tight squeezing head band
• Does not interfere with sleep
• Management
• Non-narcotic analgesic, muscle relaxant,
  tricyclic antidepressant
• Patient education

3

• Migraine
• Etiology
• ? Inflammation and dilation of intracranial blood
  vessels
• Clinical manifestations
• Two types
• Migraine without aura
• Migraine with aura
• Pain
• Steady, throbbing and synchronous with pulse
• Unilateral
• Accompanied by N V, irritability, pallor,
  desire to hibernate
• Management
• Prevention
• Beta-blockers, (propranolol Inderal)
• Abortive
• Aspirin-like drugs
• Metoclopromide (Reglan)

4

• ergotamine
• Promotes vasoconstriction and ? amplitude of
  pulsations
• Adm.---sublingual, inhalation, PO, rectal
• Side effects---NV, weakness in legs, numbness
  and tingling, can cause physical dependance
• Contraindications---concurrent use of selective
  serotonin receptor agonists, hepatic or renal
  impairment, sepsis, CAD, PVD ---Preg X
• dihydroergotamine
• Similar to above with SQ, IM, IV or nasal adm.
• Selective Serotonin Receptor Agonists
  (Triptans)
• somatriptan(Imitrex)
• Adm.---PO, inhalation, SQ
• Selectively binds to intracranial blood
  vessels to cause vasoconstriction and to the
  trigeminal nerve to ? inflammatory peptides
• Side effects---well tolerated, avoid with
  pregnancy and CAD, client may experience heavy
  arms and chest pressure

5

• Cluster
• Etiology
• Trigeminal nerve activation causes vasodilation,
  stimulation of pain fibers and neurogenic
  inflammatory reaction
• May be triggered by alcohol ingestion
• Clinical Manifestations
• A cluster of attacks lasting from 15min to 2
  hours over a period of 4-12 weeks --- may have
  remission of weeks to years
• Nonthrobbing, unilateral, usually in or around
  the eye
• Conjunctival injection, lacrimation, nasal
  congestion, rhinorrhea, miosis, ptosis
• Associated with pacing and crying out
• Deep steady, penetrating but not throbbing
• Management
• Prophylaxis
• Verapamil
• Abortive
• Sumatriptan or ergot preparation
• 100 O2
• Analgesic rebound HA
• 15 days/month

6

• Collaborative Care
• R/O organic HA caused by significant intracranial
  or extracranial disease
• HX
• Ominous signs of HA
• Abnormal physical signs
• Papilledema, widening pulse pressure, nuchal
  rigidity, fever
• New-onset, unilateral, particularly in pts. gt 35
  yoa
• Severe HA or different from previous ones
• worst HA of my life
• Is becoming more continuous or intense
• HA accompanied by vomiting but not nausea
• PE
• Diagnostic Studies
• CT or MRI to rule out aneurysm, tumor or infection

7

• Nursing Management Nursing Care Plan 57-1
• Pain
• Anxiety
• Hopelessness
• Sleep pattern disturbance

8
Describe the etiology, clinical manifestations,
diagnostic studies, and collaborative management
of epilepsy, multiple sclerosis, Parkinsons
disease, and myasthenia gravis

• Epilepsy
• EtiologySpontaneous firing of abnormal neurons
  that may spread throughout the brain (idiopathic)
  
• Clinical manifestations
• Generalized Seizures
• Tonic-clonic---loss of consciousness, stiffening
  (tonic) and jerking(clonic) movements, cyanosis,
  salivation, tongue biting, incontinence,
  postictal phase with no memory of seizure
• Typical absence---(petit mal) only in children,
  brief staring spell
• Atypical absence---staring spell accompanied by
  other signs, peculiar behavior and confusion
  afterwards
• Partial Seizures
• Simple --- no LOC
• Complex --- complex symptoms and postictal
  confusion

9

• Diagnostic studies
• EEG (often not definitive)
• R/O organic pathology
• Blood work, UA, MRI or CT (new onset), LP
• Collaborative Care (Table 57-7)
• Acute intervention
• Emergency management (Table 57-8)
• Observation
• Complications
• Status epilepticus
• Injury from trauma

10

• Psychosocial
• Patient and Family Teaching
• Drug therapy
• Phenytoin (Dilantin)
• Carbamazepine (Tegretol)
• Phenobarbitol
• Divalproex (Depakote)
• Table 57-12

11

• Multiple Sclerosis
• Etiology
• Loss of myelin and proliferation of astrocytes ?
  plaque formation (sclerosis) throughout the CNS
• Early in the process myelin is damaged but
  replaces itself ? remission
• Progression ? total myelin disruption with axon
  involvement and permanent loss of nerve function

12

• Clinical Manifestations
• Insidious onset/vague symptoms between 15 and 50
  YOA
• More prevalent in temperate climated
• Chronic, progressive / remissions and
  exacerbations Table 57-13
• Relapsing-remitting MS
• Primary-progressive MS
• Secondary-progressive MS
• Progressive-relapsing MS
• Signs/symptoms
• Weakness or paralysis of limbs, trunk, head,
  diplopia, muscle spasticity, numbness tingling,
  patchey blindness (scotomas), blurred vision,
  vertigo, tinnitus, nystagmus, dysarthria
• Bowel and bladder symptoms vary
• Sexual dysfunction

13

• Collaborative Management
• Diagnosis
• No definitive test for MS
• HX and clinical manifestations
• MRI
• Sclerotic plaques 3-4 mm
• Characteristic white-matter lesions scattered
  throughout the brain and spinal cord
• Drug therapy
• ACTH and prednisone
• Antiinflammatory during acute exacerbations
• Immunosuppressive drugs

14

• Immunomodulators --- control disease, decrease
  new lesions and remissions
• Beta-interferon (Betaseron)
• Interferon-B1a (Avonex)
• Anticholinergics may help with urinary
  urgency/frequency
• Muscle Relaxants
• Baclofen(Lioresal)
• Nursing management 57-3 NCP
• Impaired physical mobility
• Self-care deficits
• Risk for impaired skin integrity
• Sensory-perceptual alterations
• Altered urinary elimination
• Constipation
• Sexual dysfunction
• Self-esteem disturbance
• Altered family processes

15

• Parkinsons Disease
• A syndrome characterized by slowing in initiation
  and execution of movement (bradykinesia),
  increased muscle tone (rigidity), tremor, and
  impaired postural reflexes
• Etiology
• Unknown
• Pathophysiology
• Degeneration of dopamine-producing neurons in the
  substantia nigra of the midbrain causing an
  imbalance between the neurotransmitters
  acetylcholine and dopamine
• Clinical manifestations
• Gradual and insidious
• Tremor at rest, limp, ? arm movement
• Shuffling-propulsive gait, flexed arms and loss
  of postural reflexes, speech changes

16
(No Transcript)
17

• Complications
• Loss of spontaneous movement
• Swallowing (dysphagia) ? malnutrition, aspiration
• General lack of movement ? pneumonia, UTIs, skin
  breakdown
• Orthostatic hypotension
• Seborrhea
• Collaborative Care
• Drug therapy (Table 57-18)
• Dopaminergic
• Levodopa with carbidopa (Sinemet) (converted to
  dopamine in the basal ganglia)
• Dopamine agonists
• Bromocriptine (Parlodel), pergolide (Permax)

18

• Anticholinergic drugs
• Trihexiphenidyl (Artane), benztropin (Cogentin),)
• Antihistamines with anticholinergic properties
• Dephenhydramine (Benadryl)
• Antiviral
• Amantadine (Symmetrel)
• MAO inhibitor
• selegiline (Eldepryl)
• Surgical Therapy
• Nutritional Therapy

19

• Nursing Management (NCP 57-4)
• Impaired physical mobility
• Self Care deficits
• Impaired verbal communication
• Constipation
• Altered nutrition
• Diversional activity deficit
• Sleep pattern disturbance

20

• Myasthenia Gravis
• Disease of the neuromuscular junction
  characterized by fluctuating weakness of certain
  skeletal muscle groups
• Etiology
• Autoimmune process that results in production of
  antibodies directed against ACh receptors and a
  reduction in the number of ACh receptor sites at
  the neuromuscular junction ? ACh molecules are
  unable to affect muscle contraction (loss of
  muscle strength)
• Thymic tumors are found in 15 of patients

21

• Clinical manifestations
• Easy fatigability of skeletal muscles during
  activity
• Muscles most often involved
• Eyelids, chewing, swallowing, speaking, breathing
• Complications
• Aspiration and difficulty breathing (myasthenic
  crisis)
• Collaborative Management
• Diagnostic Studies
• Have the person look upward for 2-3 minutes
• Tensilon Test
• Improved muscle strength after IV
  anticholinesterase agent Tensilon
  (diagnostic)---Atropine should be readily
  available to counteract the effects of Tensilon
  if needed

22

• Drug therapy
• Anticholinesterase drugs
• Neostigmine (Prostigmin)
• Pyridostigmine (Mestinon)
• Corticosteroids
• Prednisone
• Many drugs must be used with caution in patients
  with MG
• Surgical therapy
• Removal of thymus gland
• Others
• plasmapheresis

23

• Nursing Management
• Ineffective breathing pattern related to
  intercostal weakness
• Ineffective airway clearance
• Impaired verbal communication
• Altered nutrition
• Sensory/perceptual alterations related to ptosis,
  
• ? eye movements,
• Activity intolerance
• Body image disturbance

24
Describe the clinical manifestations and
collaborative care of amyotrophic lateral
sclerosis and Huntingtons chorea

• Amyotrophic lateral sclerosis
• Progressive loss of motor neurons with weakness
  of upper extremities, dysartheria, dysphagia,
  muscle wasting and death from respiratory
  infection 2-5 years after diagnosis
• Care is to support the pts cognitive and
  emotional functions by facilitating
  communication, providing diversional therapies,
  and helping the family with planning and
  anticipatory grieving
• Huntingtons disease
• Genetically transmitted autosomal dominant
  disorder that affects both men and women with off
  spring having a 50 risk of inheriting the
  disease
• Excess dopamine that leads to symptoms opposite
  from Parkinsons Disease
• Onset around 35-45 years --- excessive
  involuntary movements (chorea)
• Death occurs 10-20 years after onset of symptoms
• Care is palliative
• Drug therapy
• Safety
• Nutrition

25
Explain the potential impact of chronic
neurologic disease on physical and psychologic
well-being
26
Outline the major goals of treatment for the
patient with a chronic, progressive neurologic
disease