Unit 1 Part 2 Care of the Patient with a Neurological Disorder

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Unit 1 - Part 2 - Care of the Patient with a
Neurological Disorder

• Respectively prepared by
• your instructor
• Helen M. Lucas, B.S.N., M.S.N.

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Degenerative Disorders

• cause unknown,
• premature aging of nerve cells
• or metabolic disturbance.

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The following disorders are considered
degenerative

• Multiple Sclerosis
• Parkinsons
• Alzheimers

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Multiple Sclerosis
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(No Transcript)
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Etiology

• Degenerative,
• cause is unknown,
• something goes wrong in the immune system, and
  the T-cells attack the body.
• Onset 20-40
• Course of 12 to 25 years.

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Pathophysiology

• Demyelination occurred randomly in the white
  matter of the brain stem, spinal cord, optic
  nerves, and cerebrum.
• myelin sheath and the sheath cells are destroyed
• causing an interruption or distortion of the
  impulse
• it is slowed or blocked.

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Clinical manifestations

• Visual problems
• urinary incontinence
• fatigue
• weakness or incoordination of an extremity
• sexual problems such as impotence in men
• swallowing difficulties

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Remissions may last a year

• Exacerbation's brought on by fatigue, chilling,
  or emotional disturbances.

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Assessment Subjective

• Eye prob. diplopia, scotomata (spots ), and
  blindness
• Weakness, or numbness or a part of the body
• Fatigue
• Emotional instability
• Bowel and bladder problems
• Vertigo, or loss of joint sensation
• Male impotence

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Pain uncommon
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Assessment Objective

• Nystagmus involuntary rhythmic movements of the
  eye, eye oscillates
• Muscle weakness, and spasms, changes in
  coordination, or a spastic, ataxic gait
• intention tremors of the upper extremities may be
  present
• Behavior changes euphoria, emotional lability,
  or mild depression.
• Urinary incontinence
• Difficulty in swallowing

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Diagnostic tests

• Exam of CSF shows elevated gamma globulin and a
  proliferation of gamma/delta T cells with elev.
  WBCs in initial phase
• CT scan may show enlargement of the ventricles
• MRI scan is helpful

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Medications Treatment to support Immune
abnormality
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Prednisone type drugs

• monitor electrolytes, give with food, early am.
  Used for acute and chronic symptoms. Seems to
  shorten the episode if given early when symptoms
  show up

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Interferon Beta

• Reduces relapses

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Antispasmodics

• baclofen (Lioresal),
• diazepam (Valium)
• dantrolene sodium (Dantrium)
• causes drowsiness, need side rails, Reduces
  spasticity.

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Urinary problems

• Frequency and urgency (use Pro-Banthine)
  Urecholine can exert antispasmodic affect on
  neurogenic bladder.
• Infections are a problem so Bactrim, Septra or
  Macrodantin may be used prophylactically.
  Encourage to drink at least 2000 cc. Of
  water/day.

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Nutrition

• well balanced with high fiber foods, fluids.
• Over weight patients should be referred to the
  dietitian
• Stool softener for constipation

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Skin care

• same as immobilized pt.

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Activity

• exercise regularly but not to point of fatigue
• daily rest periods
• If in acute phase bed rest may be needed
• May need gait instruction of one side is weaker
  than the other

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Control of Environment.

• Avoid hot baths, cause weakness.
• Air-conditioning best in hot weather.
• Need peaceful environment.
• Sometimes they have explosive outburst and
  family may need a lot of support.

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Pt. Teaching

• The nurse should make sure that the patient
  and/or family has the address of the nearest MS
  society or support group Prognosis
• Some pt. Live for many years with few deficits
• and other quickly become debilitated

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Parkinsons Disease
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Etiology

• common disease of the nervous system
• Average age of onset is 60s.
• 130 out 100,000 people
• Effects both sexes equally as well as all races

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Dopamine (a neurotransmitter) controls

• Posture
• support
• Voluntary motion

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Pathophysiology

• Degeneration of the dopamine-producing neurons in
  the substantia nigra of the midbrain
• Neurons facilitate movement by firing dopamine
  (neuro transmitter)
• Parkinsons sets in when roughly 80 of those
  neurons die off

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Causes

• include viral, toxic, vascular, and genetic
  causes

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Drug-induced Parkinsonian syndromes

• Antipsychotics meds frequently cause these
  symptoms especially in high doses
• Symptoms treated with Artane or Cogentin
  (anticholinergic antiparkinsonian agents)

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Symptoms
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Bradykinesia

• Slow, incomplete movement
• Patients often shuffle when they walk.

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Resting tremor

• Limbs tremble when relaxed.
• Often more pronounced on one side.
• Described as a pill-rolling motion of the fingers

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Rigidity

• Joints and muscles grow stiff and sometimes
  lock, leaving the patient frozen and unable to
  move
• Mask like appearance of the face
• Drooling, swallowing may be abnormal

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Postural instability

• Loss of balance and coordination.
• Inability to right oneself when falling down
• Propulsive gait

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Moist, oily skin

• May be scaly, erythematous rash, near the ears
  and eyebrows and the scalp and nasolabial fold

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Constipation
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Other symptoms

• Small, cramped handwriting
• Lack of arm swing
• Decreased facial expression
• Lowered voice volume, slow monotonous speech
• Impotence and depression
• All signs increase with fatigue

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Assessment Subjective

• progresses slowly
• c/o fatigue
• presence of incoordination
• judgment defects
• emotional instability and heat intolerance
• Assess pts knowledge.

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Diagnostic test no specific tests
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Clinical examination and history and pts
response to medication confirm diagnosis.
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Chemical Messages

• Normal movement requires exquisitely timed
  transfer of dopamine between cells
• This process becomes erratic in Parkinsons but
  treatment can mask the effects

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Medications

• LEVODOPA (dopamine precursor) a substance that is
  transformed into dopamine by the brain
• First dramatic break through in treatment of PD
• Causes severe nausea and vomiting

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LEVODOPA/CARBIDOPA (Sinemet) significant
improvement

• Carbidopa prevents levodopa from being
  metabolized in other tissues allowing more to get
  to the brain with smaller doses and less side
  affects.

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SYMMETREL (amantadine hydrochloride)

• Blocks reuptake of dopamine or by increasing the
  release of dopamine by neurons
• Sometimes used in addition when needed.

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ANTICHOLINERGICS

• DO NOT ACT DIRECTLY ON THE DOPAMINERGIC SYSTEM
• INSTEAD DECREASE THE ACTIVITY OF THE BALANCING
  NEUROTRANSMITTER, ACETYLCHOLINE
• But in older patients they cause confusion and
  hallucination

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SELEGILINE OR DEPRENYL (Eldepryl)

• Delays the need for Sinemet or can be used in
  later stages to boost the effects of Sinemet

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Dopamine agonists (activate the dopamine receptor
directly)

• Parlodel, Permax, Mirapex, and Requip

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COMT inhibitors

• Such as Tasmar and Comtan, new class which must
  be taken with levodopa.

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Surgical Advances

• Pallidotomy (targets source of unwanted
  movements, better accuracy now with MRI)
• Transplanting, still experimental, have used
  fetal tissue, and now genetically engineered
  cells to produce dopamine.
• Deep brain stimulation with pacemaker-like
  device, which the patient can switch on or off as
  symptoms dictate.

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Nursing Interventions
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Activity

• Maintaining posture is important.
• Firm mattress may keep spine straight
• Holding the hands folded behind the back keeps
  arms from falling stiffly at sides
• Do not hurry, bradykinesia may become worse.

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Feeding

• Aspiration is concern.
• Drooling increases with excitement.
• Keep Kleenex in pockets.

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Elimination

• Urgency
• hesitancy when voiding
• chronic constipation

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Pt. Teaching

• Take meds at prescribed times.
• Good skin care
• Keeping active to maintain mobility
• Proper positioning
• Proper feeding techniques

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Prognosis good.

• If taking meds as prescribed
• Signs and symptoms can be controlled for long
  time.

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Alzheimers Disease
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Etiology

• Causes impaired intellectual functioning
• Common cause of dementia
• Affects men and women equally
• 1 in 20 will develop Alzheimers by age 65
• 1-10 by age 75
• 1-3 by 90.
• Can strike in your 40's.

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Pathophysiology Cause unknown.

• Brain changes include plaques in the cortex and
  fibrillary degeneration within pyramidal ganglion
  cells.

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Clinical symptoms 4 Stages
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1)mild memory lapses , difficulty using the
correct word., decreased attention span,
disinterest in surroundings. Agitation and /or
restlessness
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2)Obvious memory lapses, especially with
short-term memory, time.
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3)Total disorientation to person, place, and
time. Motor problems such as apraxia (an
impairment in the ability to perform purposeful
acts) difficulty carrying out daily functions.
Wandering is common.
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4)Severe mental and physical deterioration is
present, total incontinence is common.
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All people have steady deterioration in their
physical and mental status, usually lasting 7 to
15 years until death.
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Diagnostic test

• None till autopsy.
• CT scan may be used to rule out other
  pathological conditions.

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Medical Management

• For agitation Ativan or Haldol in small doses
  may lessen agitation and unpredictable behavior.
• Cognex is used in mild to moderate dementia of
  Alzheimers type.

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Nursing Interventions
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1. Maintain adequate nutrition

• May not sit long enough to eat
• Finger foods may help
• Frequent feeding with high nutritive value
• Encourage fluids up to at least 2000 ml /day

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2. Safety

• Do to memory problems, patients do dangerous
  things
• wandering
• turning on stove
• setting fires

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Pt. Teaching

• Family need help to set realistic goals for
  patient
• allowing rest periods
• They may consider using a long term care
  facility
• Local support group for Alzheimers disease..

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Prognosis no effective treatment.
Most die from
respiratory or other infections.
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Myasthenia gravis

• Young adults, especially women
• Link with autoimmune reaction
• Unpredictable neuromuscular disease
• Antibodies attack acetylcholine receptor sites at
  the neuromuscular junction
• Interferes with transmission to muscles

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Symptoms

• WEAKNESS
• Ptosis eyelids droop
• Trunk and lower limbs affected up to respiratory
  failure

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Meds

• Anticholinesterase drugs
• Prostigmin and Mestinon
• Promote nerve impulse transmission

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Thymectomy indicated
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Vascular Problems common cause of neurological
impairment
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Cerebrovascular accident (CVA)

• BRAIN ATTACK !

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Blood vessels are occluded by embolus, thrombosis
or cerebrovascular hemorrhage
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Resulting in ischemia of the brain tissue
normally perfused by the damaged vessel
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Stroke 3rd leading cause of death in the USA

• Can affect all ages but usually the elderly.
• Related to the standard cardiac risk factors,
• same vessels just located in the brain.

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Clinical manifestations

• permanent damage caused by anoxia of the brain
• ischemic changes interrupting brain function
  depending on location.

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Pt. may experience unconsciousness and
convulsions due to abrupt hypoxia.
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Cerebral thrombosis

• most common,
• cause by atherosclerosis. Hypotension and other
  types of vascular injury such as arteritis.
• 60-90 year olds Internal carotid arteries are a
  common site of thrombosis
• occur during sleep or soon after arising.
  Position lowers BP

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Cerebral Embolism

• 2nd cause of CVA.
• Usually younger people
• Emboli most commonly originate from a thrombus in
  the heart caused by rheumatic heart disease with
  mitral stenosis and atrial fibrillation or
  myocardial infarction.
• usually in small vessels, found at points of
  bifurcation in blood vessels usually mid cerebral
  artery

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Cerebral Hemorrhage

• Intracerebral or intracranial hemorrhages include
  bleeding into the brain itself or bleeding into
  the subarachnoid space.
• Bleed causes damage by destroying and replacing
  brain tissue
• Peak incidence of aneurysms occurs in persons who
  are 35 to 60 years of age
• Women more than men.

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Transient Ischemic Attack

• Temporary episodes of neurological dysfunction
  that vary in severity
• Commonly causes Contralateral weakness of the
  lower face, hands, arms and legs transient
  dysphasia, some sensory impairment
• Between attacks, the neurological status is
  normal
• Warning of CVA in 2 - 5 years

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Assessment
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Onset of subjective symptoms

• Headache
• Sensory deficit, such as numbness or tingling,
  the inability to think clearly, and presence of
  visual problems
• Should assess patients ability to understand the
  condition.

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Objective data(1) presence of hemiparesis or
hemiplegia, change in LOC, Signs of inc. ICP,
respiratory status and presence of aphasia.
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Dominant Hemisphere

• contralateral paralysis
• paresis
• contralateral sensory loss
• dysphasia or aphasia

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Nondominant hemisphere

• spatial-perceptual problems
• changes in judgment
• contralateral (homonymous) hemianopia

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Diagnostic tests

• Lumbar puncture indicate a hemorrhage
• Ct scan show an area of decreased density.
• Brain scan will show an area of diminished
  perfusion .
• Following a TIA, a cerebral angiogram or digital
  subtraction angiogram (DSA) many be done

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Medical management
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(1) Aneurysm Surgery to tie off or clip the
aneurysm to stop bleeding. Can use plastic
coating for larger vessels.
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(2) After TIA, carotid endarterectomy can clean
out the occluded carotic artery
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(3)MEDS

• Coumadin or Heparin to prevent further clots.
• Vasodilating agents sometimes used.
• Steroids (Decadron) to reduce ICP,
• Dulcolax, stool softeners, etc. to reduce
  pressure on straining.

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(4) Fluids restricted first few days to prevent
edema of the brain. IV fluids or NG for tube
feedings
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Nursing Interventions
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(1) Survival needs Neurological assessment, at
least once a shift or q 4hrs.
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(2) Total care needed due to LOC.
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(3) Swallowing difficulties if neuromuscular
impairment.
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(4) help pt. to learn self care skills, using
one-handed dressing techniques, one-handed feeding
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(5) Incontinence, impt. to remove catheter as
soon as possible to prevent urinary tact
infection. Bladder training. Fluids 2000cc/day.
Re Train normal bowel pattern.
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(6) Return of motor impulses and movement in
involved extremities may last hours to months.
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(7) Prevent contracture, include passive
exercises, active exercise, strength-building of
unaffected side, early ambulation to promote the
return of muscle function.
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(8) Bobath Approach (treatment approach designed
to normalize muscle tone by providing as many
sensations of normal muscle tone, posture, and
movement as possible. See Rehab section in book.
Pg 621
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Loss of proprioception, including apraxia
(Impairment of the ability to perform purposeful
acts.)
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Agnosia (a total or partial loss of the ability
to recognize familiar objects or persons)
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Hemianopia (Blindness in one half of the visual
field ) Need to teach patient should be taught to
scan past the midline to the side where there is
the deficit.
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Homonymous Hemianopia Blindness in the same
visual field of both eyes.
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Unilateral neglect patients fails to recognize
that they have a paralyzed side.
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Teach pt to inspect the side of the body for
injury and to protect it from harm.
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These patients often show poor judgment and many
move impulsively or unsafe ly. Crying or
emotional lability is common. Foster patients
self esteem.
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Communication Problems
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Dysarthria

• (difficult, poorly articulated speech, resulting
  from interference in the control over the muscles
  of speech.

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Aphasia

• (Abnormal neurological condition in which
  language function is defective or absent because
  of an injury to certain areas of the cerebral
  cortex
• Communication board may helpful.
• Do not prompt or finish the sentence before the
  patient has a chance to find the appropriate
  word.
• The difficulty did not mean the patient has
  decreased cognitive abilities

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Teaching

• Teach techniques to compensate for the deficits
  suffered as a result of the stroke.
• Teach about meds for hypertension and side
  effects and schedule for taking.
• Teach patients family about safety and
  communication.
• High risk for care giver stress.

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Cranial and Peripheral Nerve Disorders
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1. Trigeminal neuralgia

• caused by degeneration of or pressure on the
  nerve
• Also called tic douloureux.
• Affects persons in middle or late adulthood and
  slightly more common in women.

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Symptoms

• Excruciating, burning pain that radiates along
  one or more of the three divisions of the fifth
  cranial nerve.
• Pain typically extends only to the midline of the
  face and head
• Also trigger points, slight stimulus will
  initiate pain. (Drafts, touch, jarring of bed,
  do not urge pat to wash or shave the affected
  area or to comb the hair, avoid hot or cold
  liquids)

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Meds

• Tegretol
• Can inject absolute alcohol in nerve, provides
  relief for weeks to months.
• Patients may have surgical resect of the sensory
  root
• May get herpes simplex of lips.

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Nursing intervention

• Nutrition due to pain being triggered with temp,
  chewing.
• May be undernourished and dehydrated.

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2. Bells Palsy (peripheral facial paralysis)

• Caused by inflammatory process involving the
  facial nerve (VII) Can be unilateral or
  bilateral.

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Clinical manifestations

• Unilateral weakness of the facial muscles
  resulting in inability to wrinkle the forehead,
  close the eyelid, pucker the lips, or retract the
  mouth on that side.
• Loss of taste reduction of saliva on affected
  side, pain behind the ear, ringing in ear or
  other hearing loss

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Prognosis

• 80 recover fully in weeks or months may take as
  long as a year.

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Infection and Inflammation

• Interference with function because of infection
  or inflammation.

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Etiology

• Upper respiratory infection
• Infected tooth
• Open head injury

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SS

• presence of discomfort include headache or stiff
  neck
• difficulty in thinking
• presence of weakness
• inability to carry out ADLs.
• Fever, vomiting, abnormal CT, seizures, altered
  respiratory patterns, tachycardia

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Diagnostics

• CSF analysis
• CT scan or an EEG

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Nursing interventions

• Assess LOC
• Quiet environment
• Low light (photosensitivity)
• Seizure precautions

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Meds

• Antibiotics
• Steroids
• Anti seizure
• IV fluids

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Guillain-Barré Syndrome (Polyneuritis)
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Etiology

• Results in widespread inflammation and
  demyelination of the peripheral nervous system.
• Any age., men or women.
• Cause is unknown.
• Could be a viral agent or an autoimmune reaction

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Symptoms

• Onset of weakness
• Symmetrical muscle weakness starts in lower
  extremities and moves upward to include thorax
  upper extremities, face.
• Respiratory Failure

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Medical management

• Adrenocortical steroids used to treat the signs
  and symptoms
• may use plasma exchanges
• Trach, Ventilated assistance

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Nursing interventions

• Monitor respiratory function
• Watch for hypoxia
• Mental process is not impaired
• ROM is important to allow complete recovery.