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Peripheral Neurological Disorders & Central Nervous Center

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Peripheral Neurological Disorders & Central Nervous Center

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Peripheral Neurological Disorders & Central Nervous Center

  1. 1. Peripheral Neurological Disorders MG, GB
  2. 2. Common Nursing Diagnoses(there are more…) <ul><li>Mobility, Impaired Physical </li></ul><ul><li>Self Care Deficit </li></ul><ul><li>Disturbed Self Esteem </li></ul><ul><li>Fatigue </li></ul><ul><li>Respiratory Function, risk for impaired </li></ul><ul><li>Risk for Injury </li></ul><ul><li>Pain </li></ul>
  3. 3. Myasthenia Gravis: “grave muscle weakness ” <ul><li>Affects about one of every 7,500 people, all ethnic groups affected </li></ul><ul><li>Onset usually between age 20 to 40 for women. Later age of onset tends to include more men. </li></ul>
  4. 4. Pathophysiology <ul><li>Autoimmune response: decreases the number of available acetylcholine receptors at the nerve to muscle junction. Antibodies bind to the receptor sites, render them useless. Without Ach receptors there is muscle weakness. </li></ul><ul><li>Frequently goes with Thymus abnormalities </li></ul>
  5. 5. Symptoms of MG: gradual onset common <ul><li>Weakness in muscles needed to talk, chew, swallow. </li></ul><ul><li>Ptosis </li></ul><ul><li>Drooling </li></ul><ul><li>Later, limb weakness, respiratory muscle weakness </li></ul>
  6. 6. High Risk Nursing Care Issues <ul><li>Choking and/or aspiration during eating and drinking </li></ul><ul><li>Insufficient breathing effort due to muscle weakness leads to respiratory crisis </li></ul><ul><li>Falling </li></ul>
  7. 7. Diagnosis of Myasthenia Gravis <ul><li>H & P: for signs and symptoms of muscle weakness, patterns </li></ul><ul><li>MRI or CT of Thymus </li></ul><ul><li>Labwork: look for increased antibody levels in blood </li></ul><ul><li>Tensilon Test. Tensilon is a short acting anticholinesterase inhibitor. Give to patient, if see dramatic but short lived improvement in symptoms, + for MG. When physician is doing test, have atropine available. </li></ul>
  8. 8. Myasthenic Crisis <ul><li>Patient with MG can present with a severe bout of symptoms, especially respiratory—may present like anxiety. </li></ul><ul><li>Prevention involves taking care re precipitants: menses, pregnancy (read in Lewis), stress, infection, over-exertion. </li></ul><ul><li>Since overmedication can also cause problems (cholinergic crisis), differentiate carefully. </li></ul>
  9. 9. Treatment with Medication <ul><li>Anticholinesterase drugs: inhibit the destruction of acetylcholine and thus make more acetlycholine available at receptor sites. </li></ul><ul><li>Two common ones are Prostigmin (neostigmine) and Mestinon (pyridostigmine). </li></ul><ul><li>Best taken about an hour prior to meals. </li></ul><ul><li>Also use prednisone (decrease inflammatory response), other immunosuppressants, plasmapheresis, thymectomy </li></ul>
  10. 10. Guillain-Barre’ Syndrome <ul><li>Acute inflammatory process with varying degrees of motor weakness and paralysis </li></ul><ul><li>Immune system destroys the myelin sheath – affects cranial, motor, and sensory neurons </li></ul>
  11. 11. Epidemiology <ul><li>0.4-1.7 cases per 100,000 </li></ul><ul><li>Affects all races and ages, but more often seen among those over 45 and Caucasian </li></ul>
  12. 12. Symptoms of GB <ul><li>Flaccid paralysis with absent reflexes </li></ul><ul><li>Respiratory weakness/failure </li></ul><ul><li>Pain and paresthesias </li></ul><ul><li>Facial weakness with double vision and trouble speaking </li></ul>
  13. 13. Respiratory Care
  14. 14. Medications
  15. 15. Other nursing care issues
  16. 19. Unit 8 CNS Problems: <ul><li>Read about Headaches and treatment </li></ul><ul><li>Read about Huntingtons Disease and treatment </li></ul><ul><li>Read about different types of Seizures </li></ul><ul><li>In this unit we will discuss Parkinson Disease, Alzheimer’s Disease, MS, and SCI in class </li></ul>
  17. 20. Multiple Sclerosis: “Many areas of patchy destruction ” <ul><li>About 250,000 to 300,000 people with MS in the USA. More common among those living in the North, Caucasian descent. </li></ul><ul><li>Typical onset is in young and middle adult years. </li></ul>
  18. 21. Destruction of Myelin Sheath
  19. 22. MS Symptoms: Early and Later <ul><li>Early: Nystagmus, diplopia, blurry vision, mild weakness, poor sensation, paresthesias. Pattern is quite variable, which makes diagnosis difficult </li></ul><ul><li>Middle/Later: More serious weakness of limbs, and can include paralysis, spasticity, ataxia. Numbness/tingling worsened. Continued eye, ear problems. </li></ul><ul><li>Bowel and Bladder function may be affected </li></ul><ul><li>Emotionally difficult disease, Labile mood. </li></ul>
  20. 23. Diagnosis of MS is Difficult <ul><li>No definitive test for MS </li></ul><ul><li>H & P remains central </li></ul><ul><li>MRI – look for plaques on neurons </li></ul><ul><li>Evoked potential study </li></ul><ul><li>CSF analysis, labwork </li></ul>
  21. 24. Medical Treatment of MS: medication therapy <ul><li>Bethanecol </li></ul><ul><li>Glucocorticoids </li></ul><ul><li>Immunosuppressants </li></ul><ul><li>Skeletal muscle relaxants, eg Baclofen and Dantrolene </li></ul>
  22. 25. MS: Multiple Nursing Care Issues <ul><li>Help the client avoid triggers to exacerbation and to moderate activity level </li></ul><ul><li>Later, immobility becomes a real issue, and the complications of immobility require vigilant care </li></ul><ul><li>Read your text re care plan. </li></ul>
  23. 26. Assessment of seizure activity <ul><li>Observe, time and document carefully </li></ul><ul><li>Body movements, character, type progression, include eye movements </li></ul><ul><li>Loss of consciousness, incontinence </li></ul><ul><li>Precipitating factors you note </li></ul><ul><li>Post seizure (ictal) response. Confusion, sleepiness common. </li></ul>
  24. 27. Issues in Seizure Precautions <ul><li>Tongue blade is outdated </li></ul><ul><li>Suction equipment nearby, IV or hep. lock if risk is high for venous access </li></ul><ul><li>Padding on bedrails/Observe client often </li></ul><ul><li>Avoid precipitants </li></ul><ul><li>Notify MD of new seizure, injury, unrelenting seizure activity </li></ul><ul><li>If client seizes, move objects away, side lying if possible, loosen tight clothing, ease to floor or bed if possible </li></ul>
  25. 28. Status Epilepticus <ul><li>Defined as seizure over 4 minutes or in rapid succession </li></ul><ul><li>Life threatening due to brain damage mainly </li></ul><ul><li>Response involves ABC’s, IV administration of anticonvulsants in a particular order. Usually valium first, if no response, dilantin and later a third drug are used. NG to control vomitus possibly. </li></ul><ul><li>Review Anticonvulsant drugs discussed earlier </li></ul>
  26. 29. Parkinson’s Disease: Triad <ul><li>1. Tremor: hands, feet, steady rate, resting, “pill rolling” </li></ul><ul><li>2. Rigidity: stiffening up, cogwheeling </li></ul><ul><li>3. Bradykinesia: less movement inc. trunk, masklike face, moving “en bloc” and festinating gait (shuffling with accelerations) </li></ul>
  27. 30. More Parkinson’s Symptoms <ul><li>Decreased volume and variability of voice </li></ul><ul><li>Micrographia </li></ul><ul><li>Depression 50% </li></ul><ul><li>Dementia 10-40% </li></ul><ul><li>Psychosis 10% </li></ul><ul><li>Chronic, progressive disease </li></ul>
  28. 31. Pathophysiology <ul><li>Pathway for disposing of flawed proteins (Uch-Ll) is disturbed, leading to neuron death in substantia nigra. There is less dopamine available, symptoms don’t occur until about 80% destroyed. </li></ul><ul><li>Gene on chromosome 4 is implicated in the disease </li></ul>
  29. 32. Nursing Care of PD <ul><li>FASE: avoid fatigue, anxiety, stimulation, and exertion </li></ul><ul><li>Multiple care issues: injury prevention, self care, nutrition, dysphagia, activity and rest, mobility, communication deficit, despair/grief, altered thought process, and knowledge deficit </li></ul>
  30. 33. Surgical Treatment of PD <ul><li>Pallidotomy: globus pallidus (which is overactive in PD) is partly ablated—SE is occasional speech impairment </li></ul><ul><li>Electronic Stimulator placement: Small wire is set into brain and has a device placed in chest wall that can be stimulated to control increased tremors </li></ul>
  31. 34. Meds for Parkinson’s D. <ul><li>Levodopa—the precursor to dopamine </li></ul><ul><li>This drug chemically reverses the effect of PD, enhances amt. of dopamine </li></ul><ul><li>SE: nausea, hypotension, agitation and hallucinations </li></ul><ul><li>After several years, efficacy may decline </li></ul><ul><li>Don’t take with B-6 or if you have narrow angle glaucoma </li></ul>
  32. 35. Sinemet: levodopa and carbidopa <ul><li>Adding carbidopa to levodopa allows smaller dose of levodopa and fewer side effects </li></ul><ul><li>Carbidopa prevents the breakdown of levodopa </li></ul><ul><li>When taking: have LFTs, RFTs, CBC </li></ul><ul><li>Many meds reverse the effect: antipsychotics, dilantin, reserpine </li></ul>
  33. 36. Selegiline: Eldepryl <ul><li>MAOB inhibitor: decreases the degradation of dopamine (note similarity to MAOIs) </li></ul><ul><li>Careful use: many serious interactions (opiods, SSRI’s, TCA’s) </li></ul><ul><li>Limit tyramine rich foods in diet (You will need to get familiar with list) </li></ul>
  34. 37. Other meds in PD <ul><li>Tasmar </li></ul><ul><li>TCA’s </li></ul><ul><li>Antihistamines </li></ul><ul><li>Symmetrel </li></ul><ul><li>Parlodel </li></ul><ul><li>Pergolide </li></ul><ul><li>Mirapex </li></ul><ul><li>Requip </li></ul><ul><li>For test know sinemet, eldepryl and be aware of others </li></ul>
  35. 38. Dementia: Basic Definitions <ul><li>Progressive deterioration in intellectual functioning – MEMORY, LEARNING, and JUDGEMENT </li></ul><ul><li>Onset insidious, chronic, and may be a primary disorder </li></ul>
  36. 39. Types of Dementias-some <ul><li>Alzheimers DAT—see pathophys. </li></ul><ul><li>Picks; prominent emotional disinhibition </li></ul><ul><li>Huntington’s Chorea: inherited, choreiform movement plus confusion </li></ul><ul><li>Infarct Dementias </li></ul><ul><li>Korsakoffs slow starvation of brain tissue ass. W/ alcoholism </li></ul><ul><li>HIV encephalopathy </li></ul>
  37. 40. Pathophysiology of DAT
  38. 41. Progression of Alzheimer’s <ul><li>Stage I: mild—forgetful. Short term memory loss, aware of problem, depression common </li></ul><ul><li>Stage II: moderate—confused. Progressive memory deficits, Instrumental ADL’s decline, Cover with confabulation, denial </li></ul><ul><li>Stage III: Severe—ambulatory dementia. Thinking and communicating decrease, all ADLs decrease, depression resolves, person not aware of deficits </li></ul><ul><li>Stage IV: Late. Loss of basic human abilities, identity of self and family gone, physical deterioration </li></ul>
  39. 42. Treatment of Alzheimers <ul><li>Recent advances—correlation with head trauma, disuse, large families </li></ul><ul><li>3 genes cause over production of alpha beta </li></ul><ul><li>Some possible protective factors-vitamin E, antiinflammatory drugs, estrogen supp. </li></ul><ul><li>Med: Tacrine/Cognex </li></ul>
  40. 43. Nursing Diagnosis (some) <ul><li>Confusion, acute and chronic </li></ul><ul><li>Caregiver role strain </li></ul><ul><li>Memory, impaired </li></ul><ul><li>Wandering </li></ul>
  41. 44. Spinal Cord Injury Epidemiology <ul><li>About 10-12,000 new cases per year, has stayed stable over past 20 years. </li></ul><ul><li>80% male/20% female; 60% are young adult males </li></ul><ul><li>Currently about ¼ million paralyzed individuals in the US </li></ul><ul><li>Most frequent causes: MVA, gunshot (17%), falls, diving, skiing, contact sport </li></ul><ul><li>50% paraplegia; 50% quadriplegia </li></ul>
  42. 45. Pathophysiology <ul><li>Injury leads to: </li></ul><ul><li>lactate and chemical release causing vasospasm </li></ul><ul><li>edema, hemorrhage </li></ul><ul><li>All within a closed space: decreased circulation (decreased O2/glucose), build up of lactic acid </li></ul>
  43. 46. More Patho <ul><li>By limiting compression and edema, cell death is minimized </li></ul><ul><li>This can affect the level of injury. </li></ul><ul><li>Even a small gain in level of injury, can mean the preservation of function of a group of muscles that can directly affect rehabilitation </li></ul>
  44. 47. Shock in SC Injury: acute period <ul><li>Neurogenic shock </li></ul><ul><li>High level of injury </li></ul><ul><li>hypotension, no persp. </li></ul><ul><li>bradycardia </li></ul><ul><li>peripheral vasodilation </li></ul><ul><li>NSG: dopamine, atropine, MAST boots, tilt table, gradual position change </li></ul><ul><li>Spinal Shock </li></ul><ul><li>Flaccid paralysis </li></ul><ul><li>No bowel or bladder tone </li></ul><ul><li>No reflex activity </li></ul><ul><li>Poikelothermia </li></ul><ul><li>NSG: keep temp WNL, foley catheter, IV fluids, Skin care, positioning, bowel regimen (suppositories) </li></ul>
  45. 48. When Spinal and Neurogenic shock subsides <ul><li>Typically see improvement in shock symptoms after 1-6 weeks. </li></ul><ul><li>Note: see spasticity, spastic bladder </li></ul><ul><li>Stabilization of VS. </li></ul><ul><li>A small percentage of clients continue to have “flaccid” paralysis </li></ul>
  46. 49. Some treatment issues in acute period <ul><li>Time is important. CNS tissue does not survive for long. </li></ul><ul><li>Stabilization of spine on site </li></ul><ul><li>Techniques for CPR –jaw thrust </li></ul><ul><li>Transfer to neuro center asap </li></ul><ul><li>Medical management with methylprednisone, mannitol, meds to stabilize BP </li></ul><ul><li>Surgical decompression and fixation/stabilization </li></ul>
  47. 50. Nursing Issues: Acute period <ul><li>Spinal / Neurogenic shock </li></ul><ul><li>Altered respiratory function </li></ul><ul><li>Prevent DVT, skin breakdown and other complications of immobility </li></ul><ul><li>Body alignment </li></ul><ul><li>Post op infection risk </li></ul>
  48. 51. Levels of Spinal Cord Innervation <ul><li>C-4 to C-6 Phrenic Nerve: diaphragm function </li></ul><ul><li>Upper Limbs C-7, C-8 </li></ul><ul><li>T-1 to T-6 Intercostal muscles </li></ul><ul><li>T-1to L-4 Sympathetic outflow (HR, bronchiole dilation, temp control) </li></ul><ul><li>Bowel and Bladder at lowest level </li></ul>
  49. 52. Autonomic Dysreflexia (also called hyperreflexia) <ul><li>Excess reflex arc stimulation, which fails to be modified by messages from the brain, leads to a crisis. </li></ul><ul><li>Sky high BP with bradycardia, headache, sweating, blurred vision </li></ul><ul><li>Can result in a CVA </li></ul><ul><li>NSG: raise HOB, Monitor VS, give antihypertensive if needed, eliminate source of excess reflex activity such as kinked catheter, full bowel, etc. </li></ul>
  50. 53. More Notes about Nursing Issues: Enduring Problems <ul><li>Depression and suicide are common </li></ul><ul><li>About ¼ patients have chronic pain and spasticity (antispasmodics) </li></ul><ul><li>About 1/10 patients have decubiti </li></ul><ul><li>Altered respiratory function at higher levels of injury is a continued concern-aspiration, atelectasis </li></ul>
  51. 54. Nursing Care Concerns <ul><li>Triple logroll technique to maintain body alignment </li></ul><ul><li>Skeletal/halo traction and care: pin care, skin care under brace, proper fit </li></ul><ul><li>Read in text re level of injury and related ability and rehab potential </li></ul>

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