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Chapter 54 Care of the Patient with a Neurologic Disorder Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Overview of Anatomy and Physiology • Structural divisions – 2 main – Central nervous system (CNS) • Brain and spinal cord – Peripheral nervous system – 2 main • Somatic nervous system – Sends messages from the CNS to the skeletal muscles; voluntary • Autonomic nervous system – Sends messages from the CNS to the smooth muscle, cardiac muscle, and certain glands; involuntary Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 2 Overview of Anatomy and Physiology • Cells of the nervous system – 2 broad categories – Category one: • neurons – transmitter cells – Space between each neuron is called a synapse – Category two: • neuroglial or glial cells – support cells Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 3 Overview of Anatomy and Physiology – Neuron (nerve cell) : 3 Main structures • Cell Body: contains a nucleus surrounded by cytoplasm • Axon: cylindric extension of the nerve cell that conducts impulses away from the neuron cell body • Dendrites: branching structures that extend from a cell body and receive impulses Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 4 Overview of Anatomy and Physiology – Neuromuscular junction: is the area of contact between the ends of a large myelinated nerve fiber and a fiber of skeletal muscle. The neurotransmitters act to make sure that the neurological impulse passes from the nerve to the muscle. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 5 Overview of Anatomy and Physiology Neurotransmitters: chemicals that modify or result in the transmission of impulses between synapses • Acetylcholine: role in nerve impulse transmission; spills into the synapses area and speeds up transmission of the impulse. Enzyme cholinesterase is then released to deactivate the acetylcholine once the message or impulse has been sent. • Norepinephrine: has an effect on maintaining arousal (awakening from a deep sleep), dreaming, and regulation of mood (happiness or sadness). Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 6 Overview of Anatomy and Physiology • Neurotransmitters: cont. • Dopamine: affects motor function (gross subconscious movements of the skeletal muscles), also plays a role in emotional response. Parkinson’s disease there is a decrease in dopamine levels. This causes the tremors, or involuntary, trembling muscles • Serotonin: induces sleep, affects sensory perception, controls temperature, and helps regulate mood Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 7 Overview of Anatomy and Physiology • Neuron coverings: – Myelin – white, waxy, fatty material covering many nerve fibers (axons and dendrites). Increases rate of transmission of impulses and protects and insulates the fibers. • Axons leaving the CNS are wrapped in layers of myelin with indentations called Nodes of Ranvier; which further increase the rate of transmission, because the impulse can jump from node to node. • In the Peripheral nervous system the myelin is produced by Schwann cells. Outer membrane of the Schwann cells gives rise to another layer called the neurilemma. Neurilemma is a very important layer, because it helps regenerate injured axons. This only occurs in the peripheral nervous system. Cells damaged in the CNS result in permanent damage (paralysis), because they do not have neurilemma and are not able to regenerate. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 8 Figure 54-1 (A, B, from Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby. ) A, Diagram of a typical neuron. B, Myelinated axon. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 9 Overview of Anatomy and Physiology • Central nervous system: One of two main divisions of the nervous system and composed of the brain and spinal cord. Cranium protects the brain. Vertebral column protects the spinal cord – Brain: specialized cells in the brain’s mass of convoluted, soft, gray or white tissue coordinate and regulate the functions of the CNS. One of largest organs weighing approximately 3 pounds (6.6 kg). Divided into 4 principal parts: the cerebrum, diencephalon, cerebellum, and the brainstem. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 10 Overview of Anatomy and Physiology • Cerebrum • Largest part of the brain. Divided into Right and Left hemispheres. Outer portion of brain composed of gray matter and is called the cerebral cortex. Arranged in folds call gyri, grooves are sulci (fissures). Connecting structure is the corpus callosum, divides the two hemispheres into 4 lobes. Controls initiation of movement on the opposite side of the body. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 11 Overview of Anatomy and Physiology • Diencephalon: often called the interbrain, it lies beneath the cerebrum. It contains the thalamus and the hypothalamus. – Thalamus serves as a relay station for some sensory impulses while interpreting other sensory messages such as pain, light touch, and pressure. – Hypothalamus lies beneath the thalamus, plays vital role in control of body temperature, fluid balance, appetite, and certain emotions, such as fear, pleasure, and pain. » Both the sympathetic and parasympathetic divisions are under the control of the hypothalamus. The hypothalamus influences heartbeat, contraction and relaxation of the walls of the blood vessels, hormone secretion, and other vital body functions. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 12 Overview of Anatomy and Physiology • Cerebellum: lies posterior and inferior to the cerebrum and is the second largest portion of the brain. Contains 2 hemispheres. Responsible for coordination of voluntary movement and maintenance of balance, equilibrium, and muscle tone. – Sensory messages form the semicircular canals in the inner ear send their messages to the cerebellum Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 13 Overview of Anatomy and Physiology – Brain stem: located at the base of the brain and contains the midbrain, pons, and medulla oblongata – Midbrain: forms the superior portion of the brainstem. Responsible for motor movement, relay of impulses, and auditory and visual reflexes. Is the origin of cranial nerves III and IV. – Pons: connects the midbrain to the medulla oblongata. Is the origin of cranial nerves V through VIII. Composed of myelinated nerve fibers and responsible for sending impulses to the structures that are inferior and superior to it. Also contains the respiratory center and compliments the respiratory center in the medulla. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 14 Overview of Anatomy and Physiology • Brain Stem cont. – Medulla oblongata: distal portion of the brainstem. Origin of cranial nerves IX and XII. Controls heartbeat, rhythm of breathing, swallowing, coughing, sneezing, vomiting, and hiccups (singultus). A vasomotor center regulates the diameter of the blood vessels, which aids in the control of the blood pressure – Coverings of the brain and spinal cord: Brain and spinal cord are surrounded by three protective coverings called the meninges: 1) the dura mater (the outer layer) 2) arachnoid membrane (second layer) 3) pia mater (the inner most layer) which provides oxygen and nourishment to the nervous tissue. These layers also bathe the spinal cord and brain in CSF Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 15 Overview of Anatomy and Physiology • Ventricles: 4 in all, are spaces located in the brain. The CSF, which is clear and resembles plasma, flows into the subarachnoid spaces around the brain and the spinal cord and cushions them. Contains proteins, glucose, urea, and salts; it also contains certain substances that form a protective barrier that prevents harmful substances from entering the brain and spinal cord. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 16 Overview of Anatomy and Physiology • Spinal cord: is a 17”-18” cord that extends from the brainstem to the second lumbar vertebra. 2 main functions: conducting impulses to and from the brain and serving as a center for reflex actions. Responsible for reflex activities, such as knee jerks. Sensory neuron sends information to the cord, a central neuron interprets the impulse, and motoneuron sends the message back to the muscle or organ involved. Thus message is sent, interpreted, and acted upon without traveling to the brain Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 17 Figure 54-2 (From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.) Sagittal section of the brain (note position of midbrain). Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 18 Overview of Anatomy and Physiology • Peripheral nervous system: comprises the motor nerves, sensory nerves, and ganglia outside the brain and spinal cord. – Spinal nerves: 31 pairs, all mixed nerves. This means that they transmit sensory information to the spinal cord through afferent neurons and motor information from the CNS to the various areas of the body through efferent neurons. Spinal nerves are named according to the corresponding vertebra (e.g. C1, C2). – Cranial nerves: 12 pairs, attach to the posterior surface of the brain, mainly the brainstem. Conduct impulses between the head, neck, and brain, excluding the vagus nerve (X), also serves organs in the thoracic and abdominal cavaties. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 19 Overview of Anatomy and Physiology • Autonomic nervous system: controls the activities of the smooth muscle, cardiac muscle, and all glands. Is a subdivision of the peripheral nervous system. Primary function is to maintain internal homeostasis; EX. Maintain a normal heartbeat, constant body temperature, and a normal respiratory rate. Has 2 divisions that are antagonistic. One slows and one accelerates the action. • Sympathetic nervous system: prepares the body for “fight or flight” Parasympathetic nervous system: Calms the • body after a crisis Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 20 Figure 54-4 (From Thibodeau, G. A., Patton, K. T. Anthony’s textbook of anatomy and physiology. [18th ed.]. St. Louis: Mosby.) Neural pathway involved in the patellar reflex. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 21 Overview of Anatomy and Physiology • Effects of normal aging on the nervous system – Loss of brain weight – Loss of neurons (1% a year after age 50) – Reduction in cerebral blood flow – Decrease in brain metabolism and oxygen utilization – Decreased blood supply to spinal cord causes decreased reflexes – Older Adult Considerations: Neurological Disorders List p 1933 (5th ed) p1892 (6th ed) Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 22 Overview of Anatomy and Physiology • Prevention of neurological problems – Avoid drug and alcohol use – Safe use of motor vehicles – Safe swimming practices – Safe handling and storage of firearms – Use of hardhats in dangerous construction areas – Use of protective padding as needed for sports – Preventing neurological Injuries List p1933 (5th ed) p1892 (6th ed) Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 23 Assessment of the Neurological System • History: Comprehensive history essential for diagnosing neurological disease. Be specific about symptoms experienced as well as pt. understanding. Information from family may also be helpful. – Symptoms/Subjective data that may be significant include: • A) Headaches – especially those that first occur after middle age or those that change in character; headaches that are worse in the morning or awaken a person from a sleep are especially significant. • B) Clumsiness or loss of function in an extremity • C) Change in visual acuity • D) Any new or worsened seizure activity • E) Numbness or tingling in one or more extremities • F) Pain in an extremity or other part of the body • G) Personality changes or mood swings • H) Extreme fatigue or tiredness Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 24 Assessment of the Neurological System • Mental status: Assessment of the neurological pt’s mental status is important and is done with every assessment. It generally includes: – – – – – – Orientation to person, place, time, and purpose Mood and behavior General knowledge (such as names of presidents) Short and long term memory Attention span Ability to concentrate • DOCUMENTATION: is key to determining a change. – Nurse should vary orientation questions so pt doesn’t memorize answers through repetition. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 25 Assessment of the Neurological System • Level of consciousness (LOC): is the earliest and most sensitive indicator that something is changing. A decrease in LOC is the earliest sign of increased intracranial pressure. LOC has 2 components, arousal and awareness. – Wakefulness is controlled by the brainstem and most fundamental part of LOC. If pt can open eyes to voice or to pain the wakefulness center in the brainstem is still functioning. – Awareness, a higher function controlled by the reticular activating system in the brainstem, is the ability to interact with others. Has 4 parts: • 1. Orientation – person, place, time, and purpose • 2. Memory: Assess short-term memory; do not ask yes or no question • 3. Calculation: example, “If you had $2 and your apple costs $1.25, how many quarters would you get back?” • 4. Fund a knowledge: Ask the patient to name the president and to tell you what’s on the national news • Restlessness, disorientation, and lethargy may be seen first. • Table 54-2 LOC (p1934 5th ed) p1894 (6th ed) Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 26 Assessment of the Neurological System • Glasgow coma scale: quick, practical and standardized system for assessing the degree of consciousness impairment in the critically ill and for predicting the duration and ultimate outcome of coma, particularly with head injuries. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 27 Assessment of the Neurological System • Language and speech – Speech is a function of the dominant hemisphere, on the left side of the brain for all right-handed people and most left-handed people. – Aphasia is an abnormal neurological condition in which the language function is defective or absent due to injury of certain areas of the cerebral cortex . – Broca’s area in the frontal lobe responsible for speech production – Wernicke’s area in the posterior part of the temporal lobe responsible for understanding speech Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 28 Assessment of the Neurological System • Language and speech – Aphasia includes all areas of language, including speech, reading, writing, and understanding. Aphasia has been subdivided as follows: • 1. Sensory aphasia or receptive aphasia: inability to comprehend the spoken word or written word • 2. Motor aphasia: inability to use symbols of speech (aka expressive aphasia) • 3. Global aphasia: inability to understand the spoken word or to speak • Anomia is a form of aphasia characterized by inability to name objects. • Dysarthria is defined as difficult, poorly articulated speech that usually results from interference in the control over the muscles of speech caused by damage to a central or peripheral nerve. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 29 Assessment of the Neurological System • Cranial nerve function: 12 pairs of nerves emerge from the cranial cavity through openings in the skull (Table 54-1 p1932 (5th ed) p1896 (6th ed)) • Motor Function: will detect abnormalities in the normal functioning of nerves and muscles. – Motor status exam includes: • • • • • Gait and stance Muscle tone Coordination Involuntary movements Muscle stretch reflexes (push-pull) Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 30 Assessment of the Neurological System • Motor function cont. – Paralysis – a loss of function – Paresis – a lesser degree of movement deficit from partial or incomplete paralysis – Flaccid – weak, soft, and flabby and lacking normal muscle with absent deep tendon reflexes – Spastic – involuntary, sudden movement or muscular contraction with increased reflexes. – Fasciculations – small, localized, spontaneous, and involuntary contractions Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 31 Assessment of the Neurological System • Sensory and perceptual status: most difficult part of the neurological exam. Alterations in sensation should be assessed include: Pain, touch, temperature, and proprioception (the sensation pertaining to spatial-position and muscular-activity stimuli originating from within the body or to the sensory receptors that those stimuli activate. • Unilateral neglect – condition in which an individual is perceptually unaware of and inattentive to oneside of the body • Hemianopia – characterized by defective vision or blindness in half of the visual field. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 32 Assessment of the Neurological System • Blood and urine – Culture- may rule out infection – Drug screens – rule out use of drugs w/ lethargy or to identify specific drugs ingested. – Arterial blood gases - used in monitoring O2 levels of the blood. Gases may be altered with neurological diseases such as Guillain-Barre’ syndrome, in which breathing patterns are altered. • Cerebrospinal fluid: Normally up to 10 lymphocytes/ml of spinal fluid. An increase of the number of lymphocytes can indicate infection such as tuberculosis, meningitis or a viral infection. – Bacterial infections often lower the glucose level as well as the chloride levels. A culture is done to determine the causative organism for meningitis. – Spinal-fluid protein is elevated when degenerative diseases or a brain tumor is present. – Blood in the spinal-fluid indicates hemorrhage from somewhere in the ventricle system. – Protein electrophoresis eval may give evident of neurological diseases such as multiple sclerosis (MS) Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 33 Assessment of the Neurological System • Computed tomography (CT [aka.cat scan]): detect pathologic conditions of the cerebrum and spinal cord using a technique of scanning without radioisotopes. Takes 20-30 minutes w/o contrast and up to 60 minutes w/ contrast and is painless (except with some discomfort with the injection of dye) NOTE: check allergies to shellfish, seafood, and/or iodine. • Brain scan: detecting pathologic conditions of the cerebrum. Uses radioactive isotopes and a scanner. Takes about 45 - 60 minutes. (If mercury is used as the isotope indicator, a mercurial diuretic Meralluride (aka..Mercuhydrin) is administered several hrs before the procedure to allow a greater concentration of the mercury to circulate to brain tissue because meralluride minimizes the uptake of mercury by the kidneys. – Used less often because CT’s and MRI’s give excellent results Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 34 Assessment of the Neurological System • MRI scan: Magnetic resonance imaging – Uses magnetic forces to image body structures – Relevance in the nervous system as a way to detect pathologic conditions of the cerebrum and spinal cord – Used to detect Stroke, multiple sclerosis, tumors, trauma, herniation, and seizure. – Greater contrast of soft-tissue vs CT scan – Diagnostic choice for neurological diseases – Caution: remove watches, credit cards, and any metal from clothing and body before entering the scanning room – Takes about 30-60 minutes • PET scan: Positron Emission Tomography Scan – Uses injection of deoxyglucose with radioactive fluorine – Gives color composite of questioned area. Shades of color give an indication of the level of glucose metabolism – Used for patients w/ stroke, Alzheimer’s disease, tumors, epilepsy, and Parkinson’s disease – Takes about 45 – 60 minutes Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 35 Assessment of the Neurological System • Lumbar puncture – To obtain CSF for examination, to relieve pressure, or introduce dye or medication – Takes about 10-15 minutes at the bedside – Caution: sharp shooting pain down one leg may occur, caused by the needle coming close to a nerve. – Usually done between L4-L5 or L5-S1 – Post procedure pt lays flat for several hours. Headache may occur (opioids are usually not helpful). • MRA: Magnetic Resonance Angiography – Differential signal characteristic of flowing blood to evaluate extracranial and intracranial blood vessels. – Provides anatomic and hemodynamic information – With or without contrast – Rapidly replacing cerebral angiography for use in dx CVA Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 36 Laboratory and Diagnostic Examinations • • • • • • • Electroencephalogram Myelogram Angiogram Carotid duplex Digital subtraction angiography Electromyogram Echoencephalogram Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 37 Assessment of the Neurological System • Electroencephalogram (EEG) – To provide function by measuring the electrical activity of the brain. – Disease assessed by EEG: epilepsy, mass lesions (tumors, abscess, hematoma), cerebrovascular lesions, and brain injury. • Myelogram – Used to identify lesions in the intradural or extradural compartments of the spinal canal by observing the flow of radiopaque dye through the subarachnoid space – Most common use is dx of herniated or protruding intervertebral disk. Other lesions include spinal tumors, adhesions, bony deformations, and arteriovenous malformations. – Water soluble iodine dyes are more often used because they are absorbed into the bloodstream and excreted by the kidneys – Site of puncture to be monitored for leakage of CSF Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 38 Assessment of the Neurological System • Angiogram – Used to visualize the cerbral arterial system by injecting radiopaque material. For detection of arterial aneurysms, vessel anomalies, ruptured vessels and displacement of vessels by tumors or masses – Takes about 2-3 hours • Carotid Duplex – Uses ultrasound and pulsed doppler technology – Noninvasive procedure that evaluates carotid occlusive disease • Electromyogram – Used to measure the contraction of a muscle in response to electrical stimulation – Takes about 45-60 minutes for one muscle study • Echoencephalogram – Uses ultrasound to depict the intracranial structures of the brain. – Helpful in detecting ventricular dilation and major shift of midline structures in the brain as a result of an expanding lesion. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 39 Figure 54-6 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [4th ed.]. St. Louis: Mosby.) Position and angle of the needle when lumbar puncture is performed. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 40 Common Disorders of the Neurological System • Headaches – Common neurological complaint; has many different causes – Etiology/pathophysiology • Skull and brain tissues are not able to feel sensory pain • Vascular headaches – Migraine » Pre-Migraine: visual field defects, unusual smells or sounds, disorientation, paresthesias » During Migraine: nausea, vomiting, sensitivity to light, chills, fatigue, irritability, diaphoresis, edema » Cause includes abnormal metabolism of serotonin, a vasoactive neurotransmitter found in platelets and cells of the brain, plays a major role. – Cluster » Aka alarm clock headache : known to wake up pt in the middle of the night with intense pain in or around the eye on one side of your head » Pain is described as sharp, penetrating or burning. » A cluster period generally lasts from six to 12 weeks » Risk factors include: Gender (men) Age (late 20’s) Smoking/Alcohol use, family history – Hypertensive » Elevated blood pressure cause increased pressure • Tension headaches – caused by tension, stress, or cervical arthritis • Traction-inflammation headaches – caused by an infection, intracranial causes, occlusive vascular structures and temporal arthritis Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 41 Common Disorders of the Neurological System • Headaches (continued) – Clinical manifestations/assessment • Head pain • Migraine headaches – Prodromal (early sign/symptom) » Visual field defects, unusual smells or sounds, disorientation, paresthesias – During headache » Nausea, vomiting, light sensitivity, chilliness, fatigue, irritability, diaphoresis, edema Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 42 Common Disorders of the Neurological System • Headaches (continued) – Medical management/nursing interventions • Pharmacological management – Migraine headaches » Aspirin, acetaminophen, ibuprofen » Ergotamine tartrate » Codeine; Inderal • Dietary recommendations – Limit MSG, vinegar, chocolate, yogurt, alcohol, fermented or marinated foods, ripened cheese, cured sandwich meat, caffeine, and pork • Psychotherapy Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 43 Common Disorders of the Neurological System • Headaches (continued) – Medical management/nursing interventions • Cluster headaches – Narcotic analgesics • Tension headaches – Non-narcotic analgesics • Traction-inflammatory headaches – Treat cause • Comfort measures – Cold packs to forehead or base of skull – Pressure to temporal arteries – Dark room; limit auditory stimulation Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 44 Common Disorders of the Neurological System • Neuropathic pain – Etiology and pathophysiology • May arise from several occurrences • The pain transmission is not fully understood – Clinical manifestations • Ranges from mild to excruciating • Changes in ability to carry out ADLs – Medical management/nursing implications • Pharmacological management – Anticonvulsants; nonopioid analgesics; antidepressants • Comfort measures Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 45 Common Disorders of the Neurological System • Increased intracranial pressure – Etiology/pathophysiology • Increase in any content of the cranium • Space-occupying lesions, cerebrospinal problems, cerebral edema – Clinical manifestations/assessment • • • • Diplopia Headache Decreased level of consciousness Pupillary signs Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 46 Common Disorders of the Neurological System • Increased intracranial pressure (continued) – Clinical manifestations/assessment (continued) • • • • • • • • • Widening pulse pressure (increased systolic/decreased diastolic) Bradycardia (pulse less than 60) Respiratory problems (poss. Cheyne stoking) High, uncontrolled temperatures Positive Babinski’s reflex (extension of the big toe while fanning the other toes.) Seizures Posturing (Decorticate, Decerebrate, or both) Vomiting Singultus (ordinary hiccup) Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 47 Common Disorders of the Neurological System • Increased intracranial pressure (continued) – Medical management/nursing interventions • Treat cause if possible • Pharmacological management – – – – Corticosteroids (dexmethasone) Antacids; histamine-receptor blockers Anticonvulsants (dilantin, cerebyx(short-term IV or IM use)) AVOID opioids and other drugs that cause respiratory depression • Mechanical decompression – Craniotomy (surgical operation in which a bone flap is temporarily removed from the skull to access the brain) – Craniectomy (Surgical removal of a portion of the cranium) • Internal monitoring devices – Ventricular pressure monitoring – catheter inserted through a burr hole into the lateral ventricle and attached to a transducer and oscilloscope to monitor ICP – Subarachnoid screw – inserted through a burr hole in skull and attached to a transducer and oscilloscope for continuous monitoring Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 48 Common Disorders of the Neurological System • Disturbances in muscle tone and motor function – Etiology/pathophysiology • Damage to the nervous system causes serious problems in mobility – Clinical manifestations/assessment • Flaccid or hyperreflexic muscle tone • Clumsiness or incoordination • Abnormal gait Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 49 Common Disorders of the Neurological System • Disturbances in muscle tone and motor function (continued) – Medical management/nursing interventions • • • • • • • Muscle relaxants Protect from falls Assess skin integrity Positioning Sit up and tuck chin when eating Encourage patient to assist with ADLs Emotional support Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 50 Other Disorders of the Neurological System • Epilepsy or seizures – Etiology/pathophysiology • Transitory disturbance in consciousness or in motor, sensory, or autonomic function due to sudden, excessive, and disorderly discharges in the neurons of the brain; results in sudden, violent, involuntary contraction of a group of muscles • Types: grand mal; petit mal; psychomotor; Jacksonian-focal; myoclonic; akinetic • Status epilepticus Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 51 Other Disorders of the Neurological System • Epilepsy or seizures (continued) – Clinical manifestations/assessment • Depends on type of seizure • Aura • Postictal period – Medical management/nursing interventions • During seizure: Protect from aspiration and injury • Anticonvulsant medications • Surgery – Removal of brain tissue where seizure occurs Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 52 Other Disorders of the Neurological System • Epilepsy or seizures (continued) – Medical management/nursing interventions (continued) • • • • Adequate rest Good nutrition Avoid alcohol Avoid driving, operating machinery, and swimming until seizures are controlled • Good oral hygiene • Medic Alert tag Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 53 Degenerative Diseases • Multiple sclerosis – Etiology/pathophysiology • Degenerative neurological disorder with demyelination of the brain stem, spinal cord, optic nerves, and cerebrum Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 54 Figure 54-13 (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.) Pathogenesis of multiple sclerosis. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 55 Degenerative Diseases • Multiple sclerosis (continued) – Clinical manifestations/assessment • • • • • • • Visual problems Urinary incontinence Fatigue Weakness Incoordination Sexual problems Swallowing difficulties Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 56 Degenerative Diseases • Multiple sclerosis (continued) – Medical management/nursing interventions • No specific treatment • Pharmacological management – – – – – – – Adrenocorticotropic hormone (ACTH) Steroids Valium Betaseron (interferon beta-1b) Avonex (interferon beta-1a) Pro-banthine; urecholine Bactrim, Septra, and Macrodantin Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 57 Degenerative Diseases • Multiple sclerosis (continued) – Medical management/nursing interventions • • • • • Nutrition Skin care Activity Environmental controls Patient teaching Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 58 Degenerative Diseases • Parkinson’s disease – Etiology/pathophysiology • Deficiency of dopamine – Clinical manifestations/assessment • Muscular tremors; bradykinesia (slow movement) • Rigidity; propulsive gait (a stooped, stiff posture with the head and neck bent forward) • Emotional instability • Heat intolerance • Decreased blinking • “Pill-rolling” motions of fingers Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 59 Figure 54-14 (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.) Nigrostriatal disorders produce parkinsonism. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 60 Degenerative Diseases • Parkinson’s disease (continued) – Medical management/nursing interventions • Pharmacological management – – – – – Levodopa Sinemet Artane Cogentin Symmetrol • Surgery – ablation of affected area vs deep brain stimulator • Activity – posture is important, best to not use a pillow – Should walk with hands behind back to maintain erect spine and decrease incidence of falling • Nutrition – malnutrition and constipation can be severe – Need foods that are appetizing and easily chewed and swallowed – Encourage 5-6 small meals a day • Elimination may feel urgency and hesitancy in voiding – Should be on a high fiber diet to help prevent chronic constipation – Encourage fluids and take a stool softener, suppositories, prune juice, or milk of magnesia Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 61 Degenerative Diseases • Nursing Diagnosis: – Impaired physical mobility, related to rigidity, bradykineia, and akinesia – Risk for aspiration related to disease process • Patient Teaching: – – – – Important to take medication as prescribed Good skin care Proper ambulation and positioning Proper feeding and eating technique to reduce risk of aspiration • Prognosis – Chronic degenerative disorder with no acute exacerbations – If pt compliant with treatment, signs and symptoms can be managed for a long period of time. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 62 Degenerative Diseases • Alzheimer’s disease (AD) – Etiology/pathophysiology • Is a chronic, progressive, degenerative disorder • Impaired intellectual functioning – Common cause of dementia in the older person and affects men and women equally. • Chronic, progressive degeneration of the cells of the brain • Brain changes include plaques in the cortex, neurofibrillary tangles, and the loss of connections between cells and cell death. Decrease in brain size • 10% age 65 or older and 50% age 85 and older have AD • Genetic link • Increased plasma levels of homocysteine are associated with a significantly increased risk of AD or dementia • Blood homocysteine levels can be lowered by eating foods rich in folic acid, such as fruits and green leafy vegetables. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 63 Degenerative Diseases • Alzheimer’s disease (continued) – Clinical manifestations/assessment = 7 stages http://alz.org/research/video/alzheimers_videos_and_ media_identifying.asp • Stage 1 – – – – Mild memory lapses; decreased attention span Difficulty in using the correct word Disinterest in surroundings and possibly depression No impairment (normal function) The person does not experience any memory problems. An interview with a medical professional does not show any evidence of symptoms of dementia. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 64 Degenerative Diseases • Alzheimer’s disease (continued) – Clinical manifestations/assessment = 7 stages • Stage 2 – – – – Obvious memory lapses, especially short-term memory Disoriented to time Loss of personal objects Loss of impulse control , behavioral manifestations of AD result from changes in brain (agitation) – Some pts develop psychotic manifestations – Decrease in sleep – Very mild cognitive decline (may be normal age-related changes or earliest signs of Alzheimer's disease) The person may feel as if he or she is having memory lapses — forgetting familiar words or the location of everyday objects. But no symptoms of dementia can be detected during a medical examination or by friends, family or co-workers. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 65 Degenerative Diseases • Alzheimer’s disease (continued) – Clinical manifestations/assessment = 7 stages • Stage 3 • • • • • – Total disorientation to person, place, and time – Apraxia ( impairment in the ability to perform purposeful acts or to use objects properly ); visual agnosia (inability to recognize objects by sight); dysgraphia (difficulty communicating via writing); wandering – Awake most of the night Mild cognitive decline (early-stage Alzheimer's can be diagnosed in some, but not all, individuals with these symptoms) Friends, family or co-workers begin to notice difficulties. During a detailed medical interview, doctors may be able to detect problems in memory or concentration. Common stage 3 difficulties include: Noticeable problems coming up with the right word or name Trouble remembering names when introduced to new people Having noticeably greater difficulty performing tasks in social or work settings Forgetting material that one has just read Losing or misplacing a valuable object Increasing trouble with planning or organizing Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 66 Degenerative Diseases • Alzheimer’s disease (continued) – Clinical manifestations/assessment = 7 stages – Stage 4 • Moderate cognitive decline (Mild or early-stage Alzheimer's disease) At this point, a careful medical interview should be able to detect clear-cut symptoms in several areas: Forgetfulness of recent events • Impaired ability to perform challenging mental arithmetic — for example, counting backward from 100 by 7s • Greater difficulty performing complex tasks, such as planning dinner for guests, paying bills or managing finances • Forgetfulness about one's own personal history • Becoming moody or withdrawn, especially in socially or mentally challenging situations Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 67 Degenerative Diseases • Alzheimer’s disease (continued) – Clinical manifestations/assessment = 7 stages – Stage 5 • Moderately severe cognitive decline (Moderate or mid-stage Alzheimer's disease) Gaps in memory and thinking are noticeable, and individuals begin to need help with day-to-day activities. At this stage, those with Alzheimer's may: Be unable to recall their own address or telephone number or the high school or college from which they graduated • Become confused about where they are or what day it is • Have trouble with less challenging mental arithmetic; such as counting backward from 40 by subtracting 4s or from 20 by 2s • Need help choosing proper clothing for the season or the occasion • Still remember significant details about themselves and their family • Still require no assistance with eating or using the toilet Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 68 Degenerative Diseases • Alzheimer’s disease (continued) – Clinical manifestations/assessment = 7 stages – Stage 6 • Severe cognitive decline (Moderately severe or mid-stage Alzheimer's disease) Memory continues to worsen, personality changes may take place and individuals need extensive help with daily activities. At this stage, individuals may: • Lose awareness of recent experiences as well as of their surroundings • Remember their own name but have difficulty with their personal history • Distinguish familiar and unfamiliar faces but have trouble remembering the name of a spouse or caregiver • Need help dressing properly and may, without supervision, make mistakes such as putting pajamas over daytime clothes or shoes on the wrong feet Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 69 Degenerative Diseases • Alzheimer’s disease (continued) – Clinical manifestations/assessment = 7 stages – Stage 6 (cont) • Experience major changes in sleep patterns — sleeping during the day and becoming restless at night • Need help handling details of toileting (for example, flushing the toilet, wiping or disposing of tissue properly) • Have increasingly frequent trouble controlling their bladder or bowels • Experience major personality and behavioral changes, including suspiciousness and delusions (such as believing that their caregiver is an impostor)or compulsive, repetitive behavior like hand-wringing or tissue shredding • Tend to wander or become lost Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 70 Degenerative Diseases • Alzheimer’s disease (continued) – Clinical manifestations/assessment = 7 stages • Stage 7 (Terminal stage) – Severe mental and physical deterioration – Hospice appropriate • Very severe cognitive decline (Severe or late-stage Alzheimer's disease) In the final stage of this disease, individuals lose the ability to respond to their environment, to carry on a conversation and, eventually, to control movement. They may still say words or phrases. • At this stage, individuals need help with much of their daily personal care, including eating or using the toilet. They may also lose the ability to smile, to sit without support and to hold their heads up. Reflexes become abnormal. Muscles grow rigid. Swallowing impaired. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 71 Degenerative Diseases • Alzheimer’s disease (continued) – Assessment • Memory loss initial sign combined w/ inability to carry out normal activities. • Diagnostic Tests – No specific test for AD • CT, EEG, MRI, and PET may be used to rule out other pathologic conditions • At times only confirmation is at autopsy Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 72 Degenerative Diseases • Alzheimer’s disease (continued) – Medical management/nursing interventions • Pharmacological management – Agitation: Lorazepam; Haldol – Dementia: Cognex ; Aricept (short-term benefit for mild cognitive impairment (MCI) , slows progression by up to 3 yrs) – Namenda used for moderate to sever (only slows symptoms not MCI) • Nutrition – Finger foods; frequent feedings; encourage fluids (2000 ml/day) – Increase foods high in folic acid and vitamin B to reduce homocysteine levels 12 • Safety – Remove burner controls at night – Double-lock all doors and windows – Constant supervision – Prognosis • NO effective treatment to stop progression • Lifespan w/ disease 5-20 yrs; cost is approximately $19,000 annually • Most pt die from complications related to the disease such as pneumonia, malnutrition, or dehydration Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 73 Degenerative Diseases • Myasthenia gravis – Etiology/pathophysiology • Autoimmune disease of the neuromuscular junction • Neuromuscular disorder; nerve impulses fail to pass at the myoneural junction; causes muscular weakness • Can occur at any age but common between ages 10 to 65. Peak in women age 20 – 30. Women more affected than men in young but equals out at older age • Infants of mothers with MG may be symptomatic at birth • 25% patient have Thymoma (cancer of the thymus) • 80% have cellular structure of the thymus gland – Clinical manifestations/assessment • Ptosis (eyelid drooping); diplopia (double vision); 15% of cases confined to the eye muscles • Skeletal weakness; ataxia (lack of voluntary coordination of muscle movements) • Dysarthria (difficulty w/ speech); dysphagia (difficulty swallowing) • Bowel and bladder incontinence • Exacerbations may be initiated by upper respiratory infections, emotional tension, and menstuation Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 74 Degenerative Diseases • Myasthenia gravis (continued) – Medical management/nursing interventions • Pharmacological management – Anticholinesterase drugs (promote nerve impulse transmission and quite effective of alleviating symptoms) » Prostigmin » Mestinon – Corticosteroids (adjunct therapy d/t immune component) » Imuran » Cyclosporine – Caution with certain drugs: » Anesthetics, antidysrhythimics, antibiotics, quinine, antipsychotics, barbituates, sedatives, hypnotics, opioids, tranquilizers, and thyroid prep – Plasmapheresis removes antibodies produced by the autoimmune response…short term fix – Thymectomy if thymoma is present – Intravenous immune globulin to reduce production of acetylcholine antibodies used only in severe relapse of MG • May require mechanical ventilation • Prognosis: chronic disease Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 75 Degenerative Diseases • Amyotrophic lateral sclerosis (ALS) – Etiology/pathophysiology • Motor neurons in the brain stem and spinal cord gradually degenerate • Electrical and chemical messages originating in the brain do not reach the muscles to activate them • Lou Gehrig’s disease famous baseball player stricken in early 1940’s • Onset between ages 40-70 (2:1 men:women) • 10% of cases is genetic defect • Effects 5 out of every 100,000 people worldwide Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 76 Degenerative Diseases • Amyotrophic lateral sclerosis (ALS) (continued) – Clinical manifestations/assessment • Weakness of the upper extremities • Head drop due to weak neck muscles • Muscle cramps – Muscle contractions called fasciculations • Dysarthria (speech difficulty) • Dysphagia (difficulty swallowing) – Choking easily – Drooling – Gagging • Muscle wasting – paralysis • Compromised respiratory function – Difficulty breathing • Weight loss • DOES NOT AFFECT THE SENSES (sight, smell, taste, hearing, touch) Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 77 Degenerative Diseases • Amyotrophic lateral sclerosis (ALS) (continued) – Medical management/nursing interventions • Diagnostics – Medical Hx. w/ strength and endurance eval (muscle tremors , spasms, twitching, or loss of muscle tissue (atrophy), twitching of tongue is common) – Abnormal reflexes, stiffness and clumsiness – Emotional incontinence – Tests may be done to rule out other causes (i.e. blood, CT or MRI, Electromyography, spinal tap, swallow studies, nerve conduction) Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 78 Degenerative Diseases • Amyotrophic lateral sclerosis (ALS) (continued) – Medical management/nursing interventions • NO CURE • Rilutec (Riluzole): slows the progression of ALS and prolongs life. Helps protect motoneurons damaged by the disease • Baclofen or diazepam: used to control spasticity that interferes with daily activities • Trihexyphenidyl or amitriptyline: used for people w/ problems of swallowing their own saliva • G-Tube placement due to choking • Complications: – – – – – – Aspiration Loss of abilty to care for self Lung failure (ARDS) Pneumonia Pressure sores Weight loss • Multidisciplinary ALS teams; emotional support; – Part of the Muscular Dystrophy Foundation » http://www.als-mda.org/?gclid=CPma4oi2vq8CFWkQNAodKC31xg – ALS Associan » http://www.alsa.org/ • Prognosis – Death. Lifespan post diagnosis typically ranges 2-6 years. Approximately 25% patients live for more than 5 years (up to 7 years) Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 79 Degenerative Diseases • Huntington’s disease – Etiology/pathophysiology • Like Parkinson’s disease involves the basal ganglia and the extrapyramidal motor system • Overactivity of the dopamine pathways • Genetically transmitted autosomal dominant disorder that affects both men and women of all races. Defect on chromosome 4 – Offspring of person w/ disease has 50% chance of developing disease – Two forms: • Adult-onset (most common) symptoms in mid 30s-40s • Early-onset symptoms occur during childhood or adolescence Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 80 Degenerative Diseases • Huntington’s disease (continued) – Clinical manifestations/assessment • Behavioral – – – – – – Hallucinations Irritability Moodiness Restlessness or fidgeting Paranoia psychosis • Abnormal and excessive involuntary movements (chorea) – – – – – – Facial movements, including grimaces Head turning to shift eye position Wild jerking of extremities face and other body parts Slow, uncontrolled movement Abnormal reflexes Hesitant speech or poor enunciation • Ataxia to immobility – Unsteady gait – “Prancing” and wide walk Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 81 Degenerative Diseases • Huntington’s disease (continued) – Clinical manifestations/assessment • Deterioration in mental functions – – – – – – Dementia Disorientation or confusion Loss of judgment Loss of memory Personality changes Speech changes – Symptoms in children • Rigidity • Slow movements • Tremors Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 82 Degenerative Diseases • Huntington’s disease (continued) – Medical management/nursing interventions • Diagnostics – CT of head may show loss of brain tissue – MRI or PET of brain – Genetic tests • Treatment – NO CURE; palliative care (treat the symptoms) • Pharmacological management – Antipsychotics: Dopamine blockers may reduce abnormal behaviors (Azilect, Clozaril, Reglan, Haloperidol) – Antidepressants (Depression and suicide common (assess for S&S)) – Antichoreas (Amantadine & tetrabenzine: used to control extra movements) – Co-enzyme Q10: help slow down the course of the disease (but not conclusive) Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 83 Degenerative Diseases • Huntington’s disease (continued) – Medical management/nursing interventions • Safe environment • Emotional support – Huntington’s Disease Society of America » www.hdsa.org • High-calorie diet – As much as 4000-5000 kcal/day to maintain body weight due to involuntary body movements • Complications – – – – – – Loss of ability to care for self Loss of ability to interact Injury to self or others Increased risk for infection Depression death • Prognosis – Causes disability that gets worse overtime – Average lifespan from onset of symptoms is 15-20 years. – Cause of death is often infection or suicide Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 84 Vascular Problems • Stroke (cerebrovascular accident [CVA]) – Etiology/pathophysiology: Blood flow to a part of the brain stops. Aka.. Brain attack • Abnormal condition of the blood vessels of the brain: 2 types – 85% thrombosis & embolism = ischemic stroke – 15% hemorrhage = hemorrhagic stroke (weak and bursts open, aneurysm, arteriovenous malformation) • Results in ischemia of the brain tissue • Most common disease of nervous system (estimated 700,000 suffer strokes each yr. and the cause of 158,000 deaths annually) • All ages affected – Greatest number between ages 75-85 • Residual effects vary from mild deficits to severe disabilities – Hemiparesis (weakness or paralysis of one side of the body), inability to walk, complete or partial dependence with ADL’s and aphasia Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 85 Figure 54-17 (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.) Three types of stroke. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 86 Vascular Problems • Stroke (cerebrovascular accident [CVA]) cont. – Risk Factors • • • • • • • Atrial Fibrillation Diabetes Family Hx of stroke High Cholesterol Increasing age >65 Race (black people are more likely to die of a stroke) Unhealthy lifestyle – – – – – Overweight or obese Drinking heavily To much fat or salt in diet Smoking Illegal drugs (cocaine) • Birth control pills Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 87 Vascular Problems • Stroke (cerebrovascular accident [CVA]) cont. – Clinical manifestations/assessment • • • • • Headache Sensory deficit Hemiparesis; hemiplegia Dysphasia or aphasia *See handout page 2 Symptoms – Diagnostics • CT – primary test for diagnosis. Used to differentiate between ischemic vs hemmorhagic • CT angiography (CTA) provides visualization of vasculature • MRI or PET used to determine extent of damage • Doppler, CTA, or MRA may be done to assess cartoids • post TIA may result in cerebral angiogram Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 88 Vascular Problems • Stroke (cerebrovascular accident) (continued) – Medical management/nursing interventions • Hemorrhagic – Surgery to repair damage – May cause vasospasm (narrowing of blood vessel, decreasing perfusion) » Occurring in 30-60% of cases post-operatively (between days 4-12). » Mortality rate as high as 50% » If not tx rapidly can cause cerebral ischemia or cerebral anoxia which leads to severe mental and physical deficits or death. • Thrombosis or embolism – Thrombolytics (plasmnogen activator t-PA, alteplase) causes lyses of clot » Must be administered within 3 hours of the onset of symptoms. The longer the wait the less effective. TIME IS A FACTOR – Heparin, Lovenox, and Coumadin (platelet inhibitors and anticoagulants – PATIENTS MUST BE SCREENED CAREFULLY BEFORE TX BEGINS » Recent hx. Of GI bleed, CT or MRI to rule out hemorrahagic stroke • • • • Decadron to reduce ICP Neurological checks at regular intervals Q8 hrs Nutritional interventions: tube feeding may be necessary or TPN Physical, occupational, and/or speech therapy – Bobath approach: designed to normalize muscle tone by providing as many sensations of normal muscle tone, posture, and movement as possible • Support Groups – American Stroke Association www.strokeassociation.org Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 89 Vascular Problems • Stroke (cerebrovascular accident) (continued) – Complications • • • • • • • • • • Aspiration Dementia Falls Loss of mobility Loss of movement or feeling in one or more parts of the body Muscle spasticity Poor nutrition Pressure ulcers Problems speaking and understanding (effects on Broca or Wernike’s area of brain) Problems thinking and/or focusing Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 90 Cranial and Peripheral Nerve Disorders • Trigeminal neuralgia – Etiology/pathophysiology • Degeneration of or pressure on the trigeminal nerve; tic douloureux • Occurs at any age • Caused by – Multiple Scleroisis – Pressure on the trigeminal nerve from a swollen blood vessel or tumor – Clinical manifestations/assessment • Excruciating, burning facial pain, electric-like spasms that last a few seconds or minutes • Pain usually one side of face • May be triggered by touch or sounds • Can be triggered by – Brushing teeth, chewing, drinking, eating, lightly touching the face, shavingl Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 91 Cranial and Peripheral Nerve Disorders • Trigeminal neuralgia – Medical management/nursing interventions • Diagnostics: – Blood tests – MRI of the head – Trigeminal reflex testing: electrical stimulation of the divisions of the trigeminal nerve and measurement of the response with standard electromyography apparatus. This testing is not readily available to most physicians, and its indications and clinical utility are still unclear • Pharmacological Management – Anti-seizure drugs (carbamazepine (Tegratol), gabapentin, phenytoin, valproate, and pregabalin) – Muscle relaxants (baclofen, clonazepam) – Tricyclic antidepressants (amitriptyline, nortriptyline) • Surgical resection of the trigeminal nerve – Within 24 hrs of resection of 5th nerve pt develops herpes simplex of the lips (cold sores) heals in about a week (5-14 days) • Avoid stimulation of face on affected side Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 92 Cranial and Peripheral Nerve Disorders • Trigeminal neuralgia – Medical management/nursing interventions • Comfort measures – – – – – – – Keep room free of drafts Avoid walking briskly to bedside of patient Place bed out of traffic area to prevent jarring of bed avoid touching the patients face Don’t urge pts to wash or shave the affected area or to comb the hair Avoid hot or cold liquids, may trigger pain Puree food and ensure that it is lukewarm. Suggest food be taken through a straw • Prognosis – Depends on cause. Pain varies and permanent relief of pain is obtained only by surgery – Pain can be disruptive to lifestyle. Can be total physical and psychological dysfunction or even suicide. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 93 Cranial and Peripheral Nerve Disorders • Bell’s palsy (peripheral facial paralysis) – Etiology/pathophysiology • Inflammatory process involving the facial nerve VII from the nucleus in the brain to the periphery • Damage to this nerve causes weakness or paralysis of these muscles • Evidence the reactivated herpes simplex (HSV) may be involved. Causing inflammation, edema, ischemia, and demyelination of the facial nerve. • Can be unilateral (one side) or bilateral (both sides) – Causes, Incidence, and risk factors • Affects 30,000-40,000 people in the USA • Cause is not clear. But may be caused by other disease processes such as: – – – – Herpes simplex HIV infection Middle ear infection Sarcoidosis - inflammation occurs in the lymph nodes, lungs, liver, eyes, skin, or other tissues Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 94 Cranial and Peripheral Nerve Disorders • Bell’s palsy (peripheral facial paralysis) – Clinical manifestations/assessment • Facial numbness or stiffness – Hard to close one eye – Problems w/ smiling, grimacing, or making facial expressions • Drawing sensation of the face – Twitching • Unilateral weakness of facial muscles – Drooping of face • Reduction of saliva – Drooling • Pain behind the ear • Ringing in ear or other hearing loss Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 95 Cranial and Peripheral Nerve Disorders • Bell’s palsy (peripheral facial paralysis) (continued) – Medical management/nursing interventions • Diagnostics – CT scan or MRI of the head – Electromyography (EMG) or Nerve conduction test to check nerves that supply the muscles of the face • Treatment – Often no tx needed. Begins to resolve immediately but may take up to months to get full muscle strength – Eye drops to lubricate if needed or an eye patch when sleeping • Pharmacological management – Corticosteroids may reduce swelling around the facial nerve – Antiviral medications in an attempt to fight off virus that may be causing bell’s palsy Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 96 Cranial and Peripheral Nerve Disorders • Bell’s palsy (peripheral facial paralysis) (continued) – Medical management/nursing interventions • • • • Electrical stimulation Moist heat Massage of the affected area Facial exercises – Prognosis • • • • Usually resolve on own Long term changes in taste Spasms of muscles or eyelids Weakness that remains in facial muscles – Complications • Excess drying of the eye surface, leading to eye ulcer or infections Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 97 Cranial and Peripheral Nerve Disorders • Guillain-Barré syndrome – Etiology/pathophysiology • Inflammation and demyelination of the peripheral nervous system • Possibly viral or autoimmune reaction • Most common in people of both sexes between the ages of 30-50 • Often follows a minor infection, such as lung or GI infection • Nerve damage causes tingling, muscle weakness, and paralysis. Guillian-Barre syndrome most often affects the nerves’ covering (myelin sheath) and causes nerve signals to move more slowly or not at all. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 98 Cranial and Peripheral Nerve Disorders • Guillain-Barré syndrome (continued) – Clinical manifestations/assessment • Symptoms are progressive • Paralysis usually starts in the lower extremities and moves upward; may stop at any point • Respiratory failure if intercostal muscles are affected • May have difficulty swallowing, breathing, and speaking • Diagnostics – – – – – Lumbar puncture ECG Electroyography (EMG) Nerve conduction velocity test Pulmonary function tests Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 99 Cranial and Peripheral Nerve Disorders • Guillain-Barré syndrome (continued) – Medical management/nursing interventions • • • • • • • Adrenocortical steroids Apheresis Mechanical ventilation Gastrostomy tube Meticulous skin care Range-of-motion exercises Complications: – – – – – – – – Respiratory failure DVT Increased risk of infections Low or unstable bp Paralysis that is permanent Pneumonia Skin damage aspiration • Prognosis: Most recover completely but can take weeks, months, or years. 30% of cases will have some residual effects Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide Cranial and Peripheral Nerve Disorders • Meningitis – Etiology/pathophysiology • Acute infection of the meninges • Bacterial or aseptic • Increased incidence in winter and fall months Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide Cranial and Peripheral Nerve Disorders • Meningitis (continued) – Clinical manifestations/assessment • • • • • • • Headache; stiff neck Irritability; restlessness Malaise Nausea and vomiting Delirium Elevated temperature, pulse, and respirations Kernig’s and Brudzinski’s signs Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide Cranial and Peripheral Nerve Disorders • Meningitis (continued) – Medical management/nursing interventions • Pharmacological management – Antibiotics » Massive doses » Multiple types » IV or intrathecal – Corticosteroids – Anticonvulsants – Antipyretics • Dark, quiet room Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide Cranial and Peripheral Nerve Disorders • Encephalitis – Etiology and pathophysiology • Acute inflammation of the brain caused by a virus – Clinical manifestations • • • • Headache Fever Seizures Change in LOC – Medical management and nursing interventions • Primarily supportive Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide Cranial and Peripheral Nerve Disorders • West Nile virus – Etiology and pathophysiology • Principal route of infection through the bite of an infected mosquito – Clinical manifestations • • • • Fever Headache Back pain Myalgia – Prevention Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide Cranial and Peripheral Nerve Disorders • Brain abscess – Etiology and pathophysiology • Accumulation of pus within the brain tissue – Clinical manifestations • • • • Headache Fever Drowsiness, changes in LOC Seizures – Medical management/nursing interventions • Antimicrobial therapy • Supportive care Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide Cranial and Peripheral Nerve Disorders • Acquired immunodeficiency syndrome – Etiology and pathophysiology • Symptoms may develop from the infection with HIV or as a result of an associated infection – Clinical manifestations • AIDS dementia complex (ADC) • Memory loss • Global cognitive dysfunction – Medical management/nursing interventions • Antiviral, antifungal, antibacterial agents • Anticonvulsants • Safety Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide Cranial and Peripheral Nerve Disorders • Brain tumors – Etiology/pathophysiology • Benign or malignant • Primary or metastatic • May affect any area of the brain Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide Cranial and Peripheral Nerve Disorders • Brain tumors (continued) – Clinical manifestations/assessment • • • • • • • • Headache Hearing loss Motor weakness Ataxia Decreased alertness and consciousness Abnormal pupil response and/or unequal size Seizures Speech abnormalities Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide Cranial and Peripheral Nerve Disorders • Brain tumors (continued) – Medical management/nursing interventions • Surgical removal of tumor – Craniotomy – Intracranial endoscopy • Radiation • Chemotherapy • Combination of above Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide Trauma • Craniocerebral trauma – Etiology/pathophysiology • Motor vehicle and motorcycle accidents, falls, industrial accidents, assaults, and sports trauma • Direct trauma: Head is directly injured • Indirect trauma: Tension strains and shearing forces • Open head injuries • Closed head injuries • Hematomas Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide Trauma • Craniocerebral trauma – Clinical manifestations/assessment • • • • • • • • Headache Nausea Vomiting Abnormal sensations Loss of consciousness Bleeding from ears or nose Abnormal pupil size and/or reaction Battle’s sign Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide Trauma • Craniocerebral trauma (continued) – Medical management/nursing interventions • • • • • Maintain airway Oxygen Mannitol and dexamethasone Analgesics Anticonvulsants Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide Trauma • Spinal cord trauma – Etiology/pathophysiology • Automobile, motorcycle, diving, surfing, other athletic accidents, and gunshot wounds • Fracture of vertebra • Complete cord injury • Incomplete cord injury Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide Figure 54-24 (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.) Mechanisms of spinal injury. Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide Trauma • Spinal cord trauma (continued) – Clinical manifestations/assessment • • • • Loss of muscle function depends on level of injury Spinal shock Autonomic dysreflexia Sexual dysfunction Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide Trauma • Spinal cord trauma (continued) – Medical management/nursing interventions • Realignment of bony column for fractures or dislocations: Immobilization; skeletal traction – Surgery for spinal decompression • Methylprednisolone • Mobility: Slowly increase sitting up • Urinary function: Foley catheter; bladder training – Intermittent catheterization • Bowel program Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide Nursing Process • Nursing diagnoses – Autonomic dysreflexia – Communication, impaired – Coping, compromised family – Disuse syndrome, risk for – Grieving – Infection, risk for – Knowledge, deficient – Memory, impaired Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide Nursing Process • Nursing diagnoses (continued) – Mobility, impaired physical – Nutrition, imbalanced: less than body requirements – Pain, acute, chronic – Self-care deficit – Swallowing, impaired – Thought process, disturbed – Tissue perfusion (cerebral), ineffective Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide