Neurologic disorders

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  • 1. Nursing Care of Clients with Neurologic Disorders   Ma. Tosca Cybil A. Torres, RN, MAN
  • 2. Outline
    • Autoimmune Disorders
      • Multiple Sclerosis (MS)
      • Myasthenia Gravis (MG)
      • Guillen-Barr é syndrome (GBS)
    • Degenerative disorders
      • Parkinson’s Disease
      • Huntington’s Disease
      • Amyotrophic Lateral Sclerosis (ALS)
  • 3. Multiple Sclerosis
  • 4. Multiple Sclerosis
    • Chronic demyelinating disease of the CNS associated with abnormal immune response to environmental factor
  • 5.  
  • 6. Multiple Sclerosis
    • Periods of exacerbations and remissions
    • Progression of disease with increasing loss of function
    • Incidence is highest in young adults (20 – 40); onset between 20 – 50
    • Affects females more than males
    • More common in temperate climates
    • Occurs mainly in Caucasians
  • 7. Manifestations
    • Fatigue
    • Optic nerve involvement: blurred vision, haziness
    • nystagmus, dysarthria,cognitive dysfunctions, vertigo, deafness
    • Weakness, numbness in leg(s), spastic paresis, bladder and bowel dysfunction
    • ataxia
    • Spasticity
    • Blindness
  • 8.
    • STRESS AGGRAVATES SYMPTOMS.
  • 9. Collaborative Care
    • Focus is on retaining optimum functioning and limiting disability
  • 10. Diagnostic Tests
    • Neurological exam, careful history
    • Lumbar puncture with CSF analysis: increased number of T lymphocytes; elevated level of immunoglobulin G (IgG)
    • Cerebral, spinal optic nerve MRI: shows multifocal lesions
    • Evoked response testing of visual, auditory, somatosensory impulses show delayed conduction
    • CT scan shows density of white matter or plaque formation
  • 11.
    • NO CURE EXISTS FOR MS
  • 12. Medications
    • Biologic response modifiers
      • Interferon beta-1a
      • Interferon beta-1b
      • Glatiramer acetate
    • Glucocorticosteroids
    • Immunosuppressants
      • azathioprine (Imuran)
      • cyclophosphamide (Cytoxan)
      • methotrexate
    • Muscle relaxants to treat muscle spasms
      • diazepam
    • Medications to deal with bladder problems: anticholinergics or cholinergics depending on problem experienced by client
  • 13. Nursing Diagnoses
    • Self care deficit
    • Impaired physical mobility
    • Risk for injury
    • Impaired urinary and bowel elimination
    • Impaired verbal communication
    • Risk for aspiration
    • Disturbed thought processes
    • Ineffective individual coping
    • Potential for sexual dysfunction
  • 14. Nursing Care
    • Monitor motor movements for interference with ADLs
    • Encourage activity balanced with rest periods
    • Assess cognitive function
    • Explain:
      • Bladder training
      • Positioning
      • Avoid temperature extremes
      • Medication compliance
      • Avoid STRESS.
  • 15. Health Promotion
    • Client needs to develop strategies to deal with fatigue, exacerbations
    • Prevention of respiratory and urinary tract infections
  • 16. Home Care
    • Education
    • Referral to support group and resources
    • Referral to home health agencies when condition requires
  • 17. Myasthenia gravis (MG)
  • 18. Myasthenia gravis (MG)
    • Chronic autoimmune neuromuscular disorder affecting the neuromuscular joint
  • 19.  
  • 20. Myasthenia gravis (MG)
    • characterized by fatigue and severe weakness of skeletal muscles
    • Occurs with remissions and exacerbations
    • Occurs more frequently in females, with onset between ages 20 – 30
  • 21. Manifestations
    • Seen in the muscles that are affected:
    • Ptosis (drooping of eyelids), diplopia (double vision)
    • Weakness in mouth muscles resulting in dysarthria and dysplagia
    • Weak voice, smile appears as snarl
    • Head juts forward
    • Muscles are weak but DTRs are normal
    • Weakness and fatigue exacerbated by stress , fever, overexertion, exposure to heat; improved with rest
  • 22.
    • MG is purely a MOTOR disorder with no effect on sensation or coordination
  • 23. Complications
    • Pneumonia
    • Myasthenic Crisis
    • Sudden exacerbation of motor weakness putting client at risk for respiratory failure and aspiration
    • Manifestations: tachycardia, tachypnea, respiratory distress, dysphasia
  • 24. Complications
    • Cholinergic Crisis
    • Occurs with overdosage of medications (anticholinesterase drugs) used to treat MG
    • Develops GI symptoms, severe muscle weakness, vertigo and respiratory distress
    • Both crises often require ventilation assistance
  • 25. Diagnostic Tests
    • Physical examination and history
    • Tensilon Test: edrophonium chloride (Tensilon) administered and client with myasthenia will show significant improvement lasting 5 minutes
    • EMG: reduced action potential
    • Antiacetylcholine receptor antibody serum levels: increased in 80% MG clients; used to follow course of treatment
    • Serum assay of circulating acetylcholine receptor antibodies: if increased, is diagnostic of MG
  • 26. Medications
    • Anticholinesterase medications
      • Pyridostigmine bromide (Mestinon)
    • Immunsuppression medications including glucocorticoids
      • Cyclosporineor azathioprine (Imuran)
  • 27. Surgery
    • Thymectomy is recommended in clients <60
    • Remission occurs in 40 % of clients, but may take several years to occur
  • 28. Plasmapheresis
    • Used to remove antibodies
    • Often done before planned surgery, or when respiratory involvement has occurred
  • 29. Nursing Care
    • Teaching interventions to deal with fatigue
    • Importance of following medication therapy
  • 30. Nursing Diagnoses
    • Ineffective Airway Clearance
    • Impaired Swallowing: plan to take medication to assist with chewing activity
  • 31. Home Care
    • Avoid fatigue and stress
    • Plan for future with treatment options
    • Keep medications available
    • Carry medical identification
    • Referral to support group, community resources
  • 32. Guillain-Barr é Syndrome (GBS)
  • 33. Guillain-Barr é Syndrome (GBS)
    • Acute autoimmune inflammatory demyelinating disorder of peripheral nervous system characterized by acute onset of ascending motor paralysis
  • 34. Guillain-Barr é Syndrome (GBS)
    • Cause is unknown but precipitating events include GI or respiratory infection, surgery, or viral immunizations
    • 80 – 90% of clients have spontaneous recovery with little or no disabilities
    • 4 – 6% mortality rate, and up to 10% have permanent disabling weakness
    • 20 % require mechanical ventilation due to respiratory involvement
  • 35. Manifestations
    • Most clients have symmetric weakness beginning in lower extremities
    • Ascends body to include upper extremities, torso, and cranial nerves
    • Sensory involvement causes severe pain, paresthesia and numbness
    • Paralysis of intercostals and diaphragmatic muscle
    • Autonomic nervous system involvement: blood pressure fluctuations, cardiac dysrhythmias, paralytic ileus, urinary retention
    • Weakness usually plateaus or starts to improve in the fourth week with slow return of muscle strength
  • 36. Diagnostic Tests
    • diagnosis made thorough history and clinical examination; there is no specific test
    • CSF analysis: increased protein
    • EMG: decrease nerve conduction
    • Pulmonary function test reflect degree of respiratory involvement
  • 37. Medications
    • supportive and prophylactic care
    • Antibiotics
    • Morphine for pain control
    • Anticoagulation to prevent thromboembolic complications
  • 38. Medical management
    • Tracheostomy
    • Plasmapheresis
    • Enteral feeding
    • IVIG
  • 39. Nursing Diagnoses
    • Ineffective breathing pattern
    • Impaired bed and physical mobility
    • Imbalanced nutrition
    • Acute Pain
    • Risk for Impaired Skin Integrity
    • Impaired Communication
    • Fear
  • 40. Nursing Care
    • Maintain respiratory function
    • Enhancing physical mobility
    • Providing adequate nutrition
    • Improving communication
    • Decreasing fear and anxiety
  • 41. Home Care
    • Clients will usually require hospitalization, rehabilitation, and eventually discharge to home
    • Client and family will need support; support groups
  • 42. Degenerative Disorders
  • 43. Parkinson’s Disease
  • 44. Parkinson’s Disease
    • Associated with decreased levels of dopamine resulting from destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia.
  • 45. Parkinson’s Disease
    • characterized by tremor at rest, muscle rigidity and akinesia (poor movement); cause unknown
    • Affects older adults mostly, mean age 60 with males more often than females
    • Parkinson-like syndrome can occur with some medications, encephalitis, toxins; these are usually reversible
  • 46. Manifestations
    • Tremor
    • at rest with pill rolling motion of thumb and fingers
    • Worsens with stress and anxiety
    • Progressive impairment affecting ability to write and eat
    • Rigidity
    • Involuntary contraction of skeletal muscles
    • Cogwheel rigidity: jerky motion
  • 47. Manifestations
    • Akinesia
    • Slowed or delayed movement that affects chewing, speaking, eating
    • May freeze: loss of voluntary movement
    • Bradykinesia: slowed movement
    • Posture instability
    • Involuntary flexion of head and shoulders, stooped leaning forward position
    • Equilibrium problems causing falls, and short, accelerated steps
    • Shuffling gait
  • 48.  
  • 49. Manifestations
    • Autonomic nervous system
    • Constipation and urinary hesitation or frequency
    • Orthostatic hypotension, dizziness with position change
    • Eczema, seborrhea
    • Depression and dementia; confusion, disorientation, memory loss, slowed thinking
    • Inability to change position while sleeping, sleep disturbance
    • Mask-like face
    • Dysphonia
  • 50. Complications
    • Impaired communication
    • Falls
    • Infection related to immobility and pneumonia
    • Malnutrition related to dysphagia
    • Skin breakdown
    • Depression and isolation
  • 51. Prognosis
    • Slow progressive degeneration
    • Eventual debilitation
  • 52. Diagnostic Tests
    • No specific test for disease
    • Drug screens to determine medications or toxins causing parkinsonism
    • EEG: slowed and disorganized pattern
  • 53. Medications
    • Antiparkinsonian- Levodopa (Larodopa)
    • antiviral therapy- amantadine (Symmetrel)
    • anticholinergics- benztropine mesylate (Cogentin)
    • Bromocriptine (Parlodel) pergolide (Permax) inhibit dopamine breakdown
    • MAOI- selegiline (Eldepryl)
    • Antihistamine- diphenhydramine hydrochloride (Benadryl)
    • Medications may lose their efficacy; response to drugs fluctuates: “on-off” effect
  • 54. Treatments
    • Deep brain stimulation
    • Stereotactic procedures
    • Pallidotomy: destruction of involved tissue
    • thalamotomy: destroys specific tissue involved in tremor
  • 55. Nursing Diagnoses
    • Impaired Physical Mobility
    • Impaired Verbal Communication
    • Impaired Nutrition: Less than body requirements
    • Self care deficit
    • Constipation
    • Disturbed Sleep Patterns
    • Ineffective coping
  • 56. Nursing Care
    • Improve mobility
    • Enhance self care activities
    • Improving bowel elimination
    • Improving nutrition
    • Enhancing swallowing
    • Improving communication supporting coping abilities
  • 57. Home Care
    • Medication education
    • Adaptation of home environment
    • Gait training and exercises
    • Nutritional teaching
  • 58. Huntington’s Disease (chorea)
  • 59. Huntington’s Disease (chorea)
    • Progressive, degenerative inherited neurologic disease characterized by increasing dementia and chorea
  • 60. Huntington’s Disease (chorea)
    • Cause unknown
    • Autosomal dominant genetic disorder
    • No cure
    • Usually asymptomatic until age of 30 – 40
    • a significant reduction (volume and activity) of acetylcholine
  • 61. Manifestations
    • Abnormal movement and progressive dementia
    • Early signs are personality change with severe depression, memory loss; mood swings, signs of dementia
    • Increasing restlessness, worsened by environmental stimuli and emotional stress; arms and face and entire body develops choreiform movements, lurching gait; difficulty swallowing, chewing, speaking
    • Slow progressive debilitation and total dependence
    • Death usually results from aspiration pneumonia or another infectious process
  • 62. Diagnostic Tests
    • Genetic testing of blood
    • CT scan shows cerebral atrophy
  • 63. Medications
    • Antipsychotic (phenothiazines and butyrophenones) to block dopamine receptors
    • Antidepressants
  • 64. Nursing Diagnoses
    • Risk for injury
    • Risk for Aspiration
    • Imbalanced Nutrition: Less than body requirements
    • Impaired Skin Integrity
    • Impaired Verbal Communication
    • Disturbed thought processes
  • 65. Nursing Care
    • Very challenging: physiological, psychosocial and ethical problems
    • Genetic counseling
  • 66. Home Care
    • Referral to agencies to assist client and family, support group and organization
  • 67. Amyotrophic Lateral Sclerosis (ALS) Lou Gehrig’s disease
  • 68. Amyotrophic Lateral Sclerosis (ALS) Disease of unknown cause in which there is a loss of motor neurons in the anterior horns of the spinal cord and the motor nuclei in the lower brain stem.
  • 69. Amyotrophic Lateral Sclerosis (ALS)
    • Progressive, degenerative neurologic disease characterized by weakness and wasting of muscles without sensory or cognitive changes
    • Several types of disease including a familial type
    • onset is usually between age of 40 – 60
    • higher incidence in males at earlier ages but equally post menopause
    • Physiologic problems involve swallowing, managing secretions, communication, respiratory muscle dysfunction
    • Death usually occurs in 2 – 5 years due to respiratory failure
  • 70. Manifestations
    • Initial: spastic, weak muscles with increased DTRs; muscle flaccidity, paresis, paralysis, atrophy; clients note muscle weakness and fasciculations; muscles weaken, atrophy; client complains of progressive fatigue; usually involves hands, shoulders, upper arms, and then legs
    • Atrophy of tongue and facial muscles result in dysphagia and dysarthria; emotional lability and loss of control occur
    • 50% of clients die within 2 – 5 years of diagnosis, often from respiratory failure or aspiration pneumonia
  • 71. Diagnostic Test
    • Testing rules out other conditions that may mimic early ALS such as hyperthyroidism, compression of spinal cord, infections, neoplasms
    • EMG to differentiate neuropathy from myopathy
    • Muscle biopsy shows atrophy and loss of muscle fiber
    • Serum creatine kinase if elevated (non-specific)
    • Pulmonary function tests: to determine degree of respiratory involvement
  • 72. Medications
    • Rilutek (Riluzole) antiglutamate
      • Prescribed to slow muscle degeneration
      • Requires monitoring of liver function, blood count, chemistries, alkaline phosphatase
  • 73. Nursing Diagnoses
    • Risk for Disuse Syndrome
    • Ineffective Breathing Pattern: may require mechanical ventilation and tracheostomy
  • 74. Nursing Care
    • Help client and family deal with current health problems
    • Plan for future needs including inability to communicate
  • 75. Home Care
    • Education regarding disease, community resources for health care assistance and dealing with disabilities
  • 76. Creutzfeldt-Jakob disease (CJD, spongiform encephalopathy)
  • 77. Creutzfeldt-Jakob disease
    • Rapid progressive degenerative neurologic disease causing brain degeneration without inflammation
  • 78. Description
    • Transmissible and progressively fatal
    • Caused by prion protein: transmission of prion is through direct contamination with infected neural tissue
    • Variant form of CJD is “mad cow disease”: believed transmitted by consumption of beef contaminated with bovine form of disease
    • Pathophysiology: spongiform degeneration of gray matter of brain
  • 79.
    • No definitive treatment.
    • Outcome is fatal.
  • 80. Manifestations
    • Onset: memory changes, exaggerated startle reflex, sleep disturbances
    • Rapid deterioration in motor, sensory, language function
    • Confusion progresses to dementia
    • Terminal states: clients are comatose with decorticate and decerebrate posturing
  • 81. Diagnostic Tests
    • Clinical pictures, suggestive changes on EEG and CT scan
    • Similar to Alzheimers in early stages
    • Final diagnosis made on postmortem exam
  • 82. Nursing Care
    • Use of standard precautions with blood and body fluids
    • Support and assistance to client and family
  • 83. Trigeminal neuralgia (tic douloureux)
  • 84. Description
    • Chronic disease of trigeminal nerve (cranial nerve V) causing severe facial pain
    • The maxillary and mandibular divisions of nerve are effected
    • Occurs more often in middle and older adults, females more than males
    • Cause is unknown
  • 85. Manifestations
    • Severe facial pain occurring for brief seconds to minutes hundreds of times a day, several times a year
    • Usually occurs unilaterally in area of mouth and rises toward ear and eye
    • Wincing or grimacing in response to the pain
    • Trigger areas on the face may initiate the pain
    • Sensory contact or eating, swallowing, talking may set off the pain
    • Often there is spontaneous remission after years, and then condition recurs with dull ache in between pain episodes
  • 86. Diagnosis
    • by physical assessment
  • 87. Medications
    • Anticonvulsants
    • carbamazepine (Tegretol)
    • phenytoin (Dilantin)
    • gabapentin (Neurotin)
  • 88. Surgery
    • Intractable pain may be treated by severing the nerve root: rhizotomy
    • Client may have lost facial sensation and have loss of corneal reflex
  • 89. Nursing Care
    • Teaching client self-management of pain
    • Maintaining nutrition
    • Preventing injury
  • 90. Bell’s Palsy
  • 91. Description
    • Disorder of seventh cranial nerve and causes unilateral facial paralysis
    • Occurs between age of 20 – 60 equally in males and females
    • Cause unknown, but thought to be related to herpes virus
  • 92. Manifestations
    • Numbness, stiffness noticed first
    • Later face appears asymmetric: side of face droops; unable to close eye, wrinkle forehead or pucker lips on one side
    • Lower facial muscles are pulled to one side; appears as if a stroke
  • 93. Prognosis
    • Majority of person recover fully in few weeks to months
    • Some persons have residual paralysis
  • 94. Diagnosis
    • based on physical examination
  • 95. Collaborative Care
    • Corticosteroids are prescribed in some cases but use has been questioned
    • Treatment is supportive
  • 96. Nursing Care
    • Teaching client self-care: prevent injury and maintain nutrition
    • Use of artificial tears, wearing eye patch or taping eye shut at night; wearing sunglasses
    • Soft diet that can be chewed easily, small frequent meals