Download M N EDICAL SURGICAL URSING

Caring for Clients With Neurologic
and Spinal Cord Disorders
1
Dr Ibraheem Bashayreh, RN, PhD
4/1/2011
MEDICAL SURGICAL
NURSING
EPILEPSY

A chronic neurologic disorder manifesting by repeated
epileptic seizures (attacks or fits) which result from
paroxysmal uncontrolled discharges of neurons within
the central nervous system (grey matter disease).

The clinical manifestations range from a major motor
convulsion to a brief period of lack of awareness. The
stereotyped and uncontrollable nature of the attacks is
characteristic of epilepsy.
4/1/2011
DEFINITION
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PATHOGENESIS
The 19th century neurologist Hughlings Jackson
suggested “a sudden excessive disorderly discharge of
cerebral neurons“ as the causation of epileptic seizures.

Recent studies in animal models of focal epilepsy
suggest a central role for the excitatory neurotransmiter
glutamate (increased in epi) and inhibitory gamma amino
butyric acid (GABA) (decreased)
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
3
EPIDEMIOLOGY AND COURSE

Epilepsy usually presents in childhood or adolescence but may
occur for the first time at any age.
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EPILEPSY
is a symptom of numerous disorders, but in the majority of
sufferers the cause remains unclear despite careful history
taking,examination and investigation!
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EPILEPSY & SEIZURES
Epilepsy is a neurological disorder characterized by
recurring seizures


4/1/2011

also known as a “seizure disorder”
A seizure is a brief, temporary disturbance in the
electrical activity of the brain
A seizure is a symptom of epilepsy
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THE BRAIN IS THE SOURCE OF EPILEPSY
• A seizure occurs when
too many nerve cells in
the brain “fire” too
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quickly causing an
“electrical storm”
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• All brain functions -including feeling,
seeing, thinking, and
moving muscles -depend on electrical
signals passed between
nerve cells in the brain
EPILEPSY - CLASSIFICATION
modern classification of the
epilepsies is based upon the nature of the
seizures rather than the presence or
absence of an underlying cause.
 Seizures which begin focally from a single
location within one hemisphere are thus
distinguished from those of a generalised
nature which probably commence in a
deeper structures (brainstem? thalami) and
project to both hemispheres
simultaneously.
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 The
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EPILEPSY - CLASSIFICATION
 Focal
seizures – account for
80% of adult epilepsies
-
Simple partial seizures
-
Complex partial seizures
-
Partial seizures secondarilly
generalised
 Generalised
seizures
 Unclassified
seizures
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CLASSIFYING EPILEPSY AND SEIZURES

Classifying epilepsy involves more than just
seizure type
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
Seizure types:
Partial
Simple
Complex
Consciousness
is maintained
Consciousness
is lost or impaired
Generalized
Absence
Convulsive
Altered awareness
Characterized by
muscle contractions
with or without loss
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of consciousness
GROUPS AT INCREASED RISK FOR
EPILEPSY





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About 1% of the general population develops epilepsy
 The risk is higher in people with certain medical
conditions:

Mental retardation
Cerebral palsy
Alzheimer’s disease
Stroke
Autism
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WHAT CAUSES EPILEPSY?
about 70% of people with epilepsy, the cause is
not known
 In the remaining 30%, the most common causes
are:






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 In
Head trauma
Infection of brain tissue
Brain tumor and stroke
Heredity
Lead poisoning
Prenatal disturbance brain development
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SYMPTOMS THAT MAY INDICATE A
SEIZURE DISORDER
of blackout or confused memory
 Occasional “fainting spells”
 Episodes of blank staring in children
 Sudden falls for no apparent reason
 Episodes of blinking or chewing at inappropriate
times
 A convulsion, with or without fever
 Clusters of swift jerking movements in babies
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 Periods
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SEIZURE TRIGGERS
medication (#1 reason)
 Stress/anxiety
 Hormonal changes
 Dehydration
 Lack of sleep/extreme fatigue
 Photosensitivity
 Drug/alcohol use; drug interactions
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 Missed
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HOW IS EPILEPSY DIAGNOSED?



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 Clinical Assessment
Patient history
Tests (blood, EEG, CT, MRI or PET scans)
Neurologic exam
 ID
of seizure type
 Clinical evaluation
to look for causes
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EPILEPSY
DIFFERENTIAL DIAGNOSIS
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The following should be considered in the diff. dg.
of epilepsy:
 Syncope attacks
 Cardiac arrythmias
 Migraine
 Hypoglycemia – seizures or intermittent
behavioral disturbances may occur.
 Narcolepsy – inappropriate sudden sleep
episodes
 Panic attacks
 PSEUDOSEIZURES – psychosomatic and
personality disorders
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EPILEPSY – INVESTIGATION
concern of the clinician is that epilepsy may
be symptomatic of a treatable cerebral lesion.
 Routine investigation: Haematology,
biochemistry (electrolytes, urea and calcium),
chest X-ray, electroencephalogram (EEG).
Neuroimaging (CT/MRI) should be performed in
all persons aged 25 or more presenting with first
seizure and in those pts. with focal epilepsy
irrespective of age.
 Specialised neurophysiological investigations:
Sleep deprived EEG, video-EEG monitoring.
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 The
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TYPES OF TREATMENT
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 Medication
 Surgery
 Nonpharmacologic
treatment
 Ketogenic diet: a high-fat, adequate-protein,
low-carbohydrate diet primarily used to treat
difficult-to-control (refractory) epilepsy in
children
 Vagus nerve stimulation
 Lifestyle modifications
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EPILEPSY - TREATMENT
4/1/2011
 The
majority of pts respond to drug therapy
(anticonvulsants). In intractable cases surgery may be
necessary. The treatment target is seizure-freedom and
improvement in quality of life!
 Basic rules for drug treatment: Drug treatment should
be simple, preferably using one anticonvulsant
(monotherapy). “Start low, increase slow“. Polytherapy is
to be avoided especially as drug interactions occur
between major anticonvulsants.
 The commonest drugs used in clinical practice are:
Carbamazepine, Sodium valproate, Phenytoin (first line drugs)
Lamotrigine, Topiramate, Levetiracetam, Pregabaline (new antiepileptic drugs AEDs)
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EPILEPSY – TREATMENT (CONT.)
pt is seizure-free for three years,
withdrawal of pharmacotherapy should be
considered. Withdrawal should be carried out
only if pt is satisfied that a further attack
would not ruin employment etc. (e.g. driving
licence). It should be performed very
carefully and slowly! 20% of pts will suffer a
further sz within 2 yrs.
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 If
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EPILEPSY – SURGICAL TREATMENT
of the pts with intractable epilepsy
will benefit from surgery.
 Epilepsy surgery procedures: Curative (removal
of epileptic focus) and palliative (seizure-related
risk decrease and improvement of the QOL)
 Curative (resective) procedures: Anteromesial
temporal resection, selective
amygdalohippocampectomy, extensive
lesionectomy, cortical resection,
hemispherectomy.
 Palliative procedures: Corpus callosotomy and
Vagal nerve stimulation (VNS).
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 A proportion
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STATUS EPILEPTICUS
condition when consciousness does not
return between seizures for more than 30
min. This state may be life-threatening with
the development of pyrexia, deepening coma
and circullatory collapse. Death occurs in 510%.
 Status epilepticus may occur with frontal
lobe lesions (incl. strokes), following head
injury, on reducing drug therapy, with
alcohol withdrawal, drug intoxication,
metabolic disturbances or pregnancy.
 Treatment: AEDs intravenously ASAP,
event. general anesthesia with propofol or
thipentone should be commenced
immediately.
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A
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POTENTIALLY DANGEROUS RESPONSES TO
SEIZURE
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DO NOT
 Put anything in the person’s mouth
 Try to hold down or restrain the person
 Attempt to give oral anti-seizure medication
 Keep the person on their back face up throughout
convulsion
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MULTIPLE SCLEROSIS
 is
an inflammatory disease in which the fatty
myelin sheaths around the axons of the brain
and spinal cord are damaged, leading to
demyelination and scarring as well as a broad
spectrum of signs and symptom
High risk groups
 Caucasian females
 Ages: 20–40
 Family history
 Cold, wet, northern U.S.
MULTIPLE SCLEROSIS

Pathophysiology
Autoimmune response with viral trigger
 Demyelination

Spinal cord
 Brain
 Nerves of the CNS

Myelin replaced with plaque
 Impulse transmission interrupted/ halted

MULTIPLE SCLEROSIS (MS)

Manifestations
 Exacerbations: Symptoms usually appear in
episodic acute periods of worsening
 and remissions: is characterized by unpredictable
relapses followed by periods of months to years of
relative quiet (remission) with no new signs of
disease activity.


Progression longer exacerbations
Triggers for exacerbations
Heat
 Sun
 Infections
 Stress

MULTISYSTEM EFFECTS OF MULTIPLE SCLEROSIS.
MULTIPLE SCLEROSIS

Long-Term Consequences





Urinary tract infections
Pressure ulcers/joint contractures
Falls
Pneumonia
Depression
MULTIPLE SCLEROSIS - MEDICATIONS

Medications
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Immunomodulators
Monoclonal antibody :are monospecific antibodies
that are the same because they are made by identical
immune cells that are all clones of a unique parent
cell.
Steroids
Antispasmotics
Urinary agents
Pharmacotherapy for fatigue
MULTIPLE SCLEROSIS – INTERDISCIPLINARY
CARE

Other Therapies
Physical therapy
 Surgical intervention

Neurectomy: is the surgical removal of a nerve or a section
of a nerve
 Rhizotomy: is a neurosurgical procedure that selectively
severs problematic nerve roots in the spinal cord, most often
to relieve the symptoms of neuromuscular conditions.

Plasmapheresis: is a blood purification procedure
used to treat several autoimmune diseases
 Nutritional support

MULTIPLE SCLEROSIS – CLIENT TEACHING

Client/Family Teaching
Triggers for exacerbations/stressors
 Medications/side effects
 Coping with deficits
 Counseling/support groups

MULTIPLE SCLEROSIS – NURSING CARE

Assessment

Motor assessment


Sensory changes




Muscle strength; chewing/swallowing
Tingling; vision changes
Mood changes
Urinary elimination patterns
Past medical/family history
MULTIPLE SCLEROSIS – NURSING CARE

Assessment
Respiratory effort
 ADLs
 Appearance

MULTIPLE SCLEROSIS – NURSING CARE

Nursing Diagnoses

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Fatigue
Self-Care Deficit
Ineffective Coping
Impaired Mobility
Risk for Injury
MULTIPLE SCLEROSIS – NURSING CARE

Evaluation
ADL
 Coping
 Knowledge level

Medications
 Diet
 Complications

PARKINSON’S DISEASE
Most common neurologic disorder in the U.S.
 1.5 million affected
 Most common over age 40
 Caucasian men vs. women

PARKINSON’S DISEASE

Pathophysiology

Deficiency of dopamine
Atrophy of cerebral cortex neurons
 Decreased dopamine receptors


Loss of inhibition of acetylcholine

Constant excitement of motor neurons
PARKINSON’S DISEASE

Manifestations of Parkinson’s

Cardinal signs
Tremor
 Rigidity
 Bradykinesia




Tremor
Rigidity of neck, shoulders, and trunk
Bradykinesia: is characterized by slowness of movement

Drooling : saliva flows outside the mouth
PARKINSON’S DISEASE - MEDICATIONS

Medications
Dopaminergics
 Dopamine agonists
 Anticholinergics
 MAOIs

PARKINSON’S DISEASE – INTERDISCIPLINARY
CARE

Other Therapies

Surgery
Pallidotomy: is a procedure where a tiny electrical probe is
placed in the globus pallidus (one of the basal ganglia of the
brain), which is then heated to to 80 degrees celsius for 60 s,
to destroy a small area of brain cells
 Stereotactic thalamotomy: is an invasive procedure,
primarily effective for tremors such as those associated with
Parkinson's Disease (PD), where a selected portion of the
thalamus is surgically destroyed (ablated).

Deep brain electrical stimulation
 Complementary therapy

Yoga
 Massage
 Acupuncture

PARKINSON’S DISEASE – CLIENT TEACHING

Client/Family Teaching
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Assistive devices
Communication techniques
Decreasing aspiration risk
Safety
Diet
Exercise
PARKINSON’S DISEASE – NURSING CARE

Assessment
Cognition, mood
 Motor functioning

Falls; stiffness; jerking movements
 “Pill-rolling”: A circular movement or tremor of the tips of
the thumb and the index finger when brought together.
 Facial muscle effects


Weight loss; chewing/swallowing
PARKINSON’S DISEASE – NURSING CARE

Diagnoses
Impaired Physical Mobility
 Impaired Verbal Communication
 Imbalanced Nutrition: Less than Body Requirements

PARKINSON’S DISEASE – NURSING CARE

Evaluation

Ability to:
Ambulate
 Chew and swallow
 Communicate



Complications
Knowledge level related to disease process
MYASTHENIA GRAVIS
is an autoimmune neuromuscular disease leading
to fluctuating muscle weakness and fatigability.
 Women ages 20–30
 Exacerbations and remissions


Triggers for exacerbations
MYASTHENIA GRAVIS

Pathophysiology
Auto-antibodies from thymus gland
 Block acetylcholine receptors
 Decrease number of receptors
 Blockage of nerve impulses


Face, lips, tongue, neck, and throat
Can affect fine motor skills
 Can affect respiratory muscles

MYASTHENIA GRAVIS

Manifestations
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Ptosis (is a drooping of the upper or lower eyelid);
diplopia (double vision)
Slurred speech
Difficulty chewing and swallowing
Respiratory insufficiency
Fatigue
Altered facial expressions
Difficulty writing
MYASTHENIA GRAVIS

Life-Threatening Complications
Cholinergic crisis: is an over-stimulation at a
neuromuscular junction due to an excess of acetylcholine
(ACh), as of a result of the inactivity (perhaps even inhibition)
of the AChE enzyme, which normally breaks down
acetylcholine
 Severe muscle weakness, nausea, vomiting
 Salivation, sweating, bradycardia
 Myasthenia crisis: is a life-threatening condition, which is defined as

weakness from acquired myasthenia gravis (MG) that is severe enough to
necessitate intubation or to delay extubation following surgery . The
respiratory failure is due to weakness of respiratory muscles.
Muscle weakness
 Inability to swallow; respiratory distress

MYASTHENIA GRAVIS - MEDICATIONS

Medications
Anticholinesterase medications
 Steroids
 Cytotoxic agents

MYASTHENIA GRAVIS – INTERDISCIPLINARY
CARE

Short-Term Treatments

Thymectomy
Removal of the thymus
 Decreased auto-antibody production


Plasmapheresis

Removes auto-antibodies
MYASTHENIA GRAVIS – CLIENT TEACHING

Client/Family Teaching

Medication regimen
Strict time schedule
 Side effects

CPR: airway management
 Symptoms of myasthenia and cholinergic crisis

MYASTHENIA GRAVIS – NURSING CARE

Assessment


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

Muscle weakness
Respiratory effort
Ability to swallow
Speech
Vision
SPINAL CORD INJURY – NURSING CARE

Assessment

Respiratory
Rate, depth, effort
 Breath sounds

Sensory level
 Elimination
 History of the trauma

SPINAL CORD INJURY – NURSING CARE

Diagnoses
Ineffective Breathing Pattern
 Impaired Physical Mobility
 Impaired Urinary Elimination/Constipation
 Situational Low Self-Esteem

SPINAL CORD INJURIES
Affect adolescent and adult males
 Motor vehicle crashes
 Falls
 Violent acts



Shootings
Sports injuries
SPINAL CORD INJURIES

Pathophysiology
Bruising or compression of cord via injury
 Bleeding into gray matter
 Inflammatory response

Edema
 Hypoxia
 Ischemia


No regeneration
SPINAL CORD INJURIES

Classifications

Level of injury
Cervical—tetraplegia: also known as quadriplegia, is
paralysis caused by illness or injury to a human that results
in the partial or total loss of use of all their limbs.
 Thoracic—paraplegia: is an impairment in motor or
sensory function of the lower extremities
 Sacral


Amount of cord damage
Complete
 Incomplete

SPINAL CORD INJURY

Complications
Decubitus (pressure) ulcers
 Pain, hypotonia, autonomic dysreflexia
 Spinal shock, orthostatic hypotension, bradycardia,
deep vein thrombosis
 Limited chest expansion, pneumonia


autonomic dysreflexia: is a potentially life threatening condition which can
be considered a medical emergency requiring immediate attention. AD occurs
most often in spinal cord-injured individuals with spinal lesions above the (T6)
spinal cord level. Acute AD is a reaction of the autonomic (involuntary) nervous
system to overstimulation. It is characterised by severe paroxysmal
hypertension (episodic high blood pressure) associated with throbbing
headaches, profuse sweating, nasal stuffiness, flushing of the skin above the
level of the lesion, bradycardia, apprehension and anxiety, which is sometimes
accompanied by cognitive impairment
SPINAL CORD INJURY

Complications
Stress ulcers, paralytic ileus, stool impaction, stool
incontinence
 Urinary retention, urinary incontinence, neurogenic
bladder, urinary tract infections, impotence,
decreased vaginal lubrication
 Joint contractures, muscle spasms, muscle atrophy,
pathologic fractures, hypercalcemia

SPINAL CORD INJURY

Special complications

Spinal shock: 30–60 minutes post injury
Loss of reflex activity below injury
 Bradycardia and hypotension
 Loss of sweating and temp control
 Bowel and bladder dysfunction
 Flaccid paralysis

SPINAL CORD INJURY

Special Complications

Autonomic dysreflexia
Exaggerated sympathetic response
 SCIs T6 or above

Involves triggers/stimuli
 Medical emergency

CERVICAL SPINAL CORD INJURIES

C1, C2, C3 no movement or sensation below the
neck


Ventilator-dependent
C4 movement and sensation of head and neck;
some partial function of the diaphragm
CERVICAL SPINAL CORD INJURIES
C5 controls head, neck, and shoulders; flexes
elbows
 C6 uses shoulder, extends wrist.
 C7–C8 extends elbow, flexes wrist, some use of
fingers

THORACIC AND SACRAL SPINAL CORD
INJURIES
T1–T5 has full hand and finger control, full use of
thoracic muscles
 T6–T10 controls abdominal muscles, has good
balance

THORACIC AND SACRAL SPINAL CORD
INJURIES
T11–L5 flexes and abducts the hips; flexes and
extends the knees
 S1–S5 full control of legs; progressive bowel,
bladder, and sexual function

SPINAL CORD INJURY – INTERDISCIPLINARY
CARE

Emergent Care





Airway, breathing circulation
Pain; sensation
Immobilization: neck, spine
Oxygenation needs
Intravenous fluids
SPINAL CORD INJURY – INTERDISCIPLINARY
CARE

Diagnostic testing
Cervical spine x-rays
 CT scan
 MRI

SPINAL CORD INJURY – INTERDISCIPLINARY
CARE

Pharmacotherapy
Corticosteroids
 Histamine blockers
 Anticoagulants
 Stool softeners

SPINAL CORD INJURY – INTERDISCIPLINARY
CARE

Stabilization/immobilization
Braces
 Body casts
 Cervical tongs/traction
 Halo vest

SPINAL CORD INJURY – INTERDISCIPLINARY
CARE

Surgical interventions
Spinal fusion
 Decompression laminectomy
 Insertion of rods

HERNIATED DISK – INTERDISCIPLINARY CARE
Treatment
 Medications for pain, muscle spasm; oral or
injected corticosteroids
 Conservative treatment (body mechanics,
exercises, firm mattress, warm moist compresses)
 Surgery: diskectomy, laminectomy, spinal fusion,
microdiskectomy

SPINAL CORD INJURY – NURSING CARE

Assessment

Respiratory
Rate, depth, effort
 Breath sounds

Sensory level
 Elimination
 History of the trauma

SPINAL CORD INJURY – NURSING CARE

Diagnoses
Ineffective Breathing Pattern
 Impaired Physical Mobility
 Impaired Urinary Elimination/Constipation
 Situational Low Self-Esteem

SPINAL CORD INJURY – NURSING CARE

Evaluation





Gas exchange/respiratory functioning
Ability to manage ADL
Bowel and bladder function
Skin integrity
Absence of system based complications
TRIGEMINAL NEURALGIA
Two sensory branches of the trigeminal nerve
 Pain along branches
 No known cause

Dental procedure/surgery
 Facial trauma
 Infection
 Tumor

TRIGEMINAL NEURALGIA

Manifestations of Trigeminal Neuralgia
Severe one-sided facial pain
 Stabbing/burning: forehead, nose, lips, cheek
 Exacerbations and remissions
 Simple actions can trigger symptoms

TRIGEMINAL NEURALGIA MEDICATIONS

Medications
Anticonvulsant carbamazepine
 Phenytoin
 Baclofen
