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Chapter 44 Care of Patients with Problems of the Central Nervous System: The Brain Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Headaches Migraine headache—chronic, episodic disorder with multiple subtypes Stages: Prodrome Aura phase Headache phase Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 2 Interventions Recognize migraine symptoms Respond and see health care provider Relieve pain and associated symptoms Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 3 Drug Therapy Abortive therapy—alleviating pain during the early aura phase or soon after the headache has started Preventive therapy Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 4 Complementary and Alternative Therapies Yoga, meditation, massage, exercise, biofeedback, relaxation techniques Acupuncture Use of herbs and nutritional therapies with approval Avoidance of trigger events that may result in migraine episodes, such as tension and stress Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 5 Cluster Headache Histamine cephalalgia Cause unknown; attributed to vasoreactivity and oxyhemoglobin desaturation Unilateral, radiating to forehead, temple, or cheek Ipsilateral tearing of the eye, rhinorrhea, ptosis, and miosis Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 6 Therapy Same types of drugs used for migraines Patient to wear sunglasses and avoid sunlight Oxygen via mask Avoidance of precipitating factors, such as anger, excitement Surgical management Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 7 Tension Headache Neck and shoulder muscle tenderness and bilateral pain at the base of the skull and in the forehead Head pain without associated symptoms Treatment—non-opioid analgesics, muscle relaxants, occasional opioids Ibuprofen plus caffeine Prophylactic treatment similar to that used in treating migraine headaches Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 8 Seizures and Epilepsy Seizure—abnormal, sudden, excessive, uncontrolled electrical discharge of neurons within the brain; may result in alteration in consciousness, motor or sensory ability, and/or behavior Epilepsy—two or more seizures experienced by a person; chronic disorder with recurrent, unprovoked seizure activity, may be caused by abnormality in electrical neuronal activity and/or imbalance of neurotransmitters (e.g., GABA) Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 9 Types of Seizures Generalized seizures Partial seizures Unclassified seizures Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 10 Types Primary or idiopathic epilepsy—not associated with any identifiable brain lesion Secondary seizures—result from an underlying brain lesion, most commonly a tumor or trauma Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 11 Seizures Risks Seizures may result from: Metabolic disorders Acute alcohol withdrawal Electrolyte disturbances Heart disease High fever Stroke Substance abuse Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 12 Nonsurgical Management Antiepileptic drugs (AEDs) Importance of compliance Health teaching Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 13 Seizure Precautions Oxygen Suction equipment Airway IV access Siderails up No tongue blades Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 14 Seizure Management Will depend on the type of seizure Observation and documentation Patient safety Side-lying position No restraints Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 15 Acute Seizure Management Lorazepam Diazepam Diastat IV phenytoin or fosphenytoin Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 16 Status Epilepticus Medical emergency Prolonged seizures lasting more than 5 minutes or repeated seizures over the course of 30 minutes Establish an airway ABGs IV push lorazepam, diazepam; rectal diazepam Loading dose IV phenytoin Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 17 Drug Therapy Evaluate most current blood level of medication, if appropriate. Be aware of drug-drug and drug-food interactions. Maintain therapeutic blood levels for maximal effectiveness. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 18 Drug Therapy (Cont’d) Do not administer warfarin with phenytoin. Document and report side and adverse effects. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 19 Patient and Family Education Antiepileptic drugs (AEDs) may not be stopped, even if seizures stop. Refer limited-income patients to social services. All states prohibit discrimination against people who have epilepsy. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 20 Patient and Family Education (Cont’d) Alternative employment may be needed. Vocational rehabilitation may be subsidized. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 21 Seizure Precautions Oxygen and suctioning equipment should be readily available. Saline lock may be necessary. Siderails should be up at all times. Padded siderail use is controversial. Place bed in lowest position. Never insert padded tongue blades into the patient’s mouth during a seizure. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 22 Seizure Management If simple partial seizure, observe the patient and document the seizure. Turn the patient on the side during a generalized tonic-clonic seizure; if possible, turn the patient’s head to prevent aspiration. Cyanosis usually is self-limiting. Do not restrain. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 23 Surgical Management Vagal nerve stimulation (VNS) Conventional surgical procedures Anterior temporal lobe resection Partial corpus callosotomy Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 24 Meningitis Meningitis—inflammation of the meninges that surround the brain and spinal cord Viral meningitis—usually self-limiting and the patient has a complete recovery Bacterial meningitis—potentially lifethreatening Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 25 Physical Assessment and Clinical Manifestations Signs and symptoms of meningitis— headache, nausea, vomiting, and fever Photophobia and indications of increased intracranial pressure Nuchal rigidity and positive Kernig’s and Brudzinski’s signs Seizure, decreased mental status, focal neurologic deficits Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 26 Laboratory Assessment of Meningitis Cerebrospinal fluid analysis Computed tomography scan Blood cultures Counterimmunoelectrophoresis Polymerase chain reaction Complete blood count X-ray study to determine presence of infection Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 27 Drug Therapy Broad-spectrum antibiotic Hyperosmolar agents Anticonvulsants Steroids (controversial) Prophylaxis treatment for those who have been in close contact with the meningitisinfected patient Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 28 Encephalitis Inflammation of the brain tissue and surrounding meninges Caused by viral agents, bacteria, fungi, or parasites Degeneration of neurons of the cortex Hemorrhage, edema, necrosis, small lacunae develop in cerebral hemispheres Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 29 Hemorrhagic Encephalitis Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 30 Interventions Prompt recognition and treatment of signs of cerebral edema, hemorrhage, and necrosis of brain tissue Establishment of patent airway Assessment of vital signs Continuous supportive care and assessment Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 31 Parkinson Disease Progressive neurodegenerative disease that is the third most common neurologic disorder of older adults Tremor, rigidity, bradykinesia, or akinesia Dopamine Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 32 Parkinson Disease (Cont’d) Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 33 Assessment Fatigue, slight tremor, problems with manual dexterity Rigidity, changes in facial expression, uncontrolled drooling, dementia, changes in voluntary movement, excessive perspiration, orthostatic hypotension No specific diagnostic tests Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 34 Drug Therapy in Parkinson Disease Dopamine agonists Catechol O-methyltransferases (COMTs) Monoamine oxidase type B (MAO-B) inhibitors Dopamine receptor antagonists Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 35 Drug Toxicity Long-term drug therapy regimens often cause delirium, cognitive impairment, decreased effectiveness of the drug, or hallucinations. Reduce medication dose. Change medications or frequency of administration. Take “drug holiday,” especially in the use of levodopa therapy. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 36 Management of Parkinson Disease Exercise and ambulation Self-management Injury prevention Nutrition Communication Psychosocial support Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 37 Management of Parkinson Disease (Cont’d) Surgical management includes: Stereotactic pallidotomy/thalamotomy Deep brain stimulation Fetal tissue transplantation Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 38 Alzheimer’s Disease Chronic, progressive, degenerative disease that accounts for 60% of dementias occurring in people older than 65 years Loss of memory, judgment, and visuospatial perception and change in personality Increasing cognitive impairment, severe physical deterioration, death from complications of immobility Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 39 Structural Changes in the Brain Alzheimer’s disease creates changes that include: Neurofibrillary tangles Neuritic plaques Vascular degeneration Changes in neurotransmitters Increased amounts of an abnormal protein, beta amyloid Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 40 Manifestations Changes in cognition Alterations in communication and language abilities Changes in behavior, personality, and judgment Changes in self-care skills Psychosocial assessment, especially patient’s reaction to changes in routine Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 41 Interventions in Alzheimer’s Disease Answer patient’s questions truthfully. Assess and treat other medical problems. Provide cognitive stimulation and memory training. Structure the environment to increase patient’s ability to function. Prevent overstimulation. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 42 Interventions Orientation and validation therapy. Promote self-management. Promote bowel and bladder continence. Assist with facial recognition. Promote communication. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 43 Drug Therapy Donepezil, galantamine, rivastigmine Memantine Antidepressants Psychotropic drugs Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 44 Risk for Injury Interventions for the patient with Alzheimer’s disease include: Coping with restlessness and wandering; ensuring patient wears identification bracelet; registering patient in Safe Return Program; providing frequent walks and structured activities Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 45 Risk for Injury (Cont’d) Ensuring safety by removing all potentially dangerous objects, particularly in case seizures occur Minimizing agitation by talking calmly and softly; displaying positive affect; making calm movements; offering diversion Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 46 Compromised Family Coping Interventions for the caregiver role: Encourage family to seek legal counsel regarding patient’s competency, need to obtain guardianship, or durable medical power of attorney, when necessary. Make caregivers and family aware of their own health and stress resulting from new responsibilities for care. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 47 Disturbed Sleep Pattern Difficulty sleeping at night with frequent naps in the day Interventions for establishing sleep pattern: Re-establish the usual day-night pattern by providing activity and exercise during the day. Establish before-bedtime ritual. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 48 Disturbed Sleep Pattern (Cont’d) Adjust treatment and medication schedule to provide for uninterrupted sleep. Give mild antianxiety agent or hypnotic. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 49 Huntington Disease Hereditary disorder transmitted as an autosomal dominant trait at the time of conception Movement disorder characterized by both neurologic and behavioral symptoms Gradual clinical onset of progressive mental status changes, leading to dementia and choreiform movements in the limbs, trunk, and facial muscles Three stages, each lasting about 5 years over an average 15 years of the disease Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 50 Management of Huntington Disease No known cure or treatment Genetic counseling Antipsychotic agents or monoaminedepleting agents used to manage movement abnormalities that are disabling or interfere with ADLs Medications to treat depression, anxiety, and obsessive-compulsive behaviors Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 51
