Chronic Neurologic Problems
Fall 2009
Headache
• The most common type of pain experienced
by humans
• Types
– Tension type headache
– Migraine headache
– Cluste...
Tension-Type Headache
• Characterized by…
– Neck and shoulder muscle pain; Bilateral pain at the base
of the skull and in ...
Migraine Headache
• Etiology and Pathophysiology
– …episodic familial disorder manifested by
unilateral, frontotemporal, t...
Migraine Headache
• Three classifications for migraine headache
• Migraines with aura
– Aura is a sensation that indicates...
Migraine Headache
• Atypical migraine (more assoc w/ teens & 20 yr olds)
– Less common
– Associated with menstrual periods...
Stages of a Migraine Headache
• Prodrome phase (specific symptoms
including food cravings; mood changes)
• Aura phase (vis...
Cluster Headache
• Less frequent than migraines
• More common in men between 20 and 50 years
of age
• Definitive cause of ...
Cluster Headache
• Intense pain felt deep in and around the eye (may radiate
to the ear and neck)
• Ipsilateral (same side...
Headaches – Other Types
• Can be first symptom of a more serious illness
• Can be accompany subarachnoid hemorrhage; brain...
Headaches
• Collaborative Care for Headaches
– Drug therapy
• Tension-type headache
– Acetaminophen and NSAIDs
• Migraine ...
Headaches:
Nursing Management
• Nursing assessment
• Nursing diagnoses
• Planning
• Nursing Implementation
• Evaluation
Headaches: Nursing Diagnoses
• Acute pain related to lack of knowledge of
pain control techniques or methods to
prevent he...
Chronic Neurologic Disorders
Other
Epilepsy
• “To be seized from a force within”
• Chronic condition characterized by recurrent
paroxysmal (sudden attack)epi...
Epilepsy
• A symptom of CNS irritation, excessive and
abnormal neuronal discharges
• Present as a manifestation of disease...
Epilepsy
• Affects 2 – 4 million people*
• Not accurate*
– Not reportable
– Individuals not likely to admit to condition
W...
Epilepsy
• Most common age groups:
– Birth to 2 years
– 5-7 years
– Early puberty (especially girls)
• 90% of all patients...
Epilepsy
• Cerebral epilepsy-cerebral lesions account for
activity, usually due to…
– Birth injuries (Example: Cerebral pa...
Epilepsy
• Biochemical epilepsy – biochemical
disorders that include epilepsy as a clinical
feature
– Alcohol ingestion/dr...
Epilepsy
• Post traumatic epilepsy – from previously
sustained cerebral injuries, few prior to 2
months or after 5 years
–...
Seizures: Terms to Remember
• Prodromal (Early warning of impending
attack)
• Aura (Visual disturbances… can be any of the...
Seizure Classification
• Generalized – bilaterally symmetric and
without local onset
– Tonic-clonic seizures (Type most co...
Seizure Classification
• Partial-focal in nature, may become generalized
– Simple/partial: No loss of consciousness
• Foca...
Clinical Manifestations
• Aura
• Tonic-hypertonic-clonic phase
– Loss of consciousness
– Bowel and bladder incontinence
– ...
Epilepsy
• Complications
– Status epilepticus (life threatening, need ER &
immediate meds… valium/diazapem and ativan,
can...
Epilepsy : Status epilepticus
• Life threatening
• Brain in a state of persistent seizure
• Continuous seizure lasting mor...
Epilepsy: Collaborative Care
• 75% can be managed successfully with
anticonvulsant medications (great list in the
book… te...
Epilepsy: Medications
• Generalized and Partial seizures
– Phenytoin (Dilantin); Side effects: gingival
hyperplasia; drug ...
Epilepsy: Medications
• Absent, Akinetic
– Klonopin; Zarotin
• Status Epilepticus
– Ativan (benzodiazepine) and Valium
Epilepsy: Surgical Intervention
• Remove focus: if alcohol w/drawal is causing seizure, then
remove the problem
• Prevent ...
Immediate Seizure Management
• During Seizure
– Provide privacy
– Maintain airway (don’t put anything in mouth, maybe put ...
When Observing a Seizure
• Prodromal
– Where there any warning signs?
• Ictus
– Where did it begin and how did it proceed?...
When Observing a Seizure
• Post-ictal
– Behavior after the seizure (describe)
– Any paralysis or weakness following the se...
Multiple Sclerosis
• Chronic, progressive, degenerative disorder of the
CNS characterized by disseminated demyelination
an...
Multiple Sclerosis
Etiology and Pathophysiology
• Cause is unknown
• Related to infectious, immunologic, and genetic
predi...
Multiple Sclerosis
Etiology and Pathophysiology
• Possibility that the association between
pathogenetic agents and MS is r...
Multiple Sclerosis
Etiology and Pathophysiology
• Possible precipitating factors include:
– Infection
– Physical injury
– ...
Multiple Sclerosis
Etiology and Pathophysiology
• Primary neuropathologic condition is an
autoimmune disease orchestrated ...
Multiple Sclerosis
Etiology and Pathophysiology
• Initially triggered by a virus in a genetically
susceptible individual
•...
Multiple Sclerosis
Etiology and Pathophysiology
• Disease process consists of loss of myelin,
disappearance of oligodendro...
Multiple Sclerosis
Etiology and Pathophysiology
• Initially the myelin sheaths of the neurons
in the brain and spinal cord...
Multiple Sclerosis
Etiology and Pathophysiology
• Myelin can be replaced by glial scar tissue
• Without myelin, nerve impu...
Multiple Sclerosis
Clinical Presentation
• Vague symptoms occur intermittently over
months and years
• Disease may not be ...
Multiple Sclerosis
Clinical Presentation
• Characterized by
– Chronic, progressive deterioration in some
– Remissions and ...
Multiple Sclerosis
Clinical Presentation: Sensory
• Numbness and tingling
• Blurred vision;diplopia (double vision)
• Vert...
Multiple Sclerosis
Clinical Presentation: Cerebellar
• Nystagmus (Involuntary movement of the eye)
• Ataxia (Inability to ...
Multiple Sclerosis
Clinical Presentation: Emotional
• Anger
• Depression
• Apathy
• Inattentiveness
• Euphoria
Multiple Sclerosis
Clinical Presentation: Other
• Bowel and bladder functions may be
impaired
– Constipation
– Spastic bla...
Multiple Sclerosis
Clinical Presentation (Other)
• Sexual dysfunction can occur in MS
- erectile dysfunction
- decreased l...
Multiple Sclerosis:
Diagnostic Studies
• Based primarily on history, clinical
presentation, and presence of multiple
plaqu...
Multiple Sclerosis:
Collaborative Care
• Drug therapy
– Corticosteroids (maintiain stability of cell wall so it doesn’t
br...
Multiple Sclerosis:
Collaborative Care
• Immunosuppressive Therapy
– Potential benefits are counterbalanced against
potent...
Multiple Sclerosis:
Collaborative Care
• Antispasmotics (any muscle, bladder, etc…)
• CNS stimulants
• Anticholinergics an...
Multiple Sclerosis:
Collaborative Care
• Surgery (for patients with severe tremor)
• Dorsal-column electrical stimulation ...
Multiple Sclerosis:
Collaborative Care
• Physical therapy helps…
– Relieve spasticity
– Increase coordination
– Trains the...
Multiple Sclerosis:
Collaborative Care
• Nutritional therapy includes…
– Megavitamins and diets consisting of low-fat,
glu...
Multiple Sclerosis:
Nursing Assessment
• Health history
– Viral infections or vaccinations
– Residence in cold or temperat...
Multiple Sclerosis:
Nursing Diagnoses
• Impaired physical mobility
• Dressing/grooming self-care deficit
• Risk for impair...
Multiple Sclerosis:
Nursing Plan of Care
• Maximize neuromuscular function
• Maintain independence in activities of daily
...
Multiple Sclerosis:
Nursing Implementation
• Help patient identify triggers and develop
ways to avoid them or minimize the...
Multiple Sclerosis:
Nursing Implementation
• Focus teaching on building general resistance
to disease
– Avoiding fatigue; ...
Multiple Sclerosis:
Nursing Implementation
• Teach self-catheterization if necessary
• Teach adequate intake of fiber to a...
Parkinson’s Disease
• Disease of basal ganglia characterized by…
– Slowing down in the initiation and execution of
movemen...
Parkinson’s Disease:
Etiology and Pathophysiology
• Pathologic process involves degeneration of
dopamine-producing neurons...
Parkinson’s Disease
• Diagnosis increases with age
• Peak onset in the 6th decade of life
• Onset before age 50 is likely ...
Parkinson’s Disease
• Clinical Presentations (goes from stage 1 to
stage 5… book gives good description of
stages)
– Sympt...
Parkinson’s Disease
• Classic triad of clinical symptoms include
– Tremor
– Rigidity
– Bradykinesia (slow movement)
– (pro...
Parkinson’s Disease
• Tremors
– More prominent at rest and aggravated by emotional
stress or increased concentration
– Des...
Parkinson’s Disease
• Rigidity (2nd classic symptom)
– Caused by sustained muscle contraction and
consequently elicits:
• ...
Parkinson’s Disease
• Bradykinesia
– Slowing down in initiation and execution of
movement-lean forward to initiate ambulat...
Parkinson’s Disease:
Complications
• Caused by progressive deterioration and loss of
spontaneity of movement
• Dysphagia c...
Parkinson’s Disease:
Complications
• Side effects from drugs, particularly levodopa,
include…
– Dyskinesia (involuntary mo...
Parkinson’s Disease:
Diagnostic Tests
• No specific tests
• Diagnosis is based on history and clinical
features
– Firm dia...
Parkinson’s Disease:
Collaborative Care
• Drug therapy –
– Aimed at correcting imbalances of
neurotransmitters within the ...
Parkinson’s Disease:
Collaborative Care
• Levodopa with carbidopa (Sinemet) is often
the first drug used
– Precursor of do...
Parkinson’s Disease:
Collaborative Care
• Effectiveness of Sinemet can wear off after a
few years of therapy
– Initiation ...
Parkinson’s Disease:
Collaborative Care
• Antihistamines with anticholinergic or beta-
adrenergic blockers are used to man...
Parkinson’s Disease:
Collaborative Care
• Surgical treatment
– Procedures aimed at relieving symptoms in patients who
are ...
Parkinson’s Disease: Collaborative Care
• Deep brain stimulation
– Involves placing an electrode in either the
thalamus, g...
Parkinson’s Disease:
Collaborative Care
• Transplantation of fetal neural tissue into the
basal ganglia provides dopamine ...
Parkinson’s Disease:
Collaborative Care
• Nutritional therapy:
– Malnutrition and constipation can be serious
consequences...
Parkinson’s Disease:
Nursing Assessment/Management
• History
– CNS trauma
– Cerebrovascular disorders
– Exposure to metals...
Parkinson’s Disease:
Nursing Assessment / Management
• History, continued
– Difficulty initiating movements; falls; loss o...
Parkinson’s Disease:
Nursing Diagnoses
• Impaired physical mobility
• Imbalanced nutrition: less than body
requirements
• ...
Parkinson’s Disease:
Nursing Management/Planning
• Maximize neurologic function (Pharm
therapy as prescribed; Pilates, whi...
Parkinson’s Disease:
Nursing Management/Implementation
• Teach maintenance of good health,
independence, and avoidance of
...
Parkinson’s Disease:
Nursing Management/Implementation
• Problems secondary to bradykinesia can be
alleviated by
– Conscio...
Parkinson’s Disease:
Nursing Management/Implementation
• Getting out of chair by using arms and
placing the back legs on s...
Myasthenia Gravis
• A chronic, progressive disease of muscular
weakness caused by a defect at the myoneural
junction (The ...
Myasthenia Gravis:
Hallmarks of the Disease
• Weakness of certain voluntary muscles
• Improvement of muscle strength at re...
Myasthenia Gravis:
Symptoms
• Muscles of the eye affected first
• Facial, masticatory, speech and neck muscles
are next
• ...
Myasthenia Gravis:
Diagnosis
• Based on history of weakness in certain
muscle groups which improve with rest
• Tensilon te...
Myasthenia Gravis:
Medical Management
• Anticholinesterase drugs facilitate impulse
across neuromuscular junctions
– Neost...
Myasthenia Gravis:
Nursing Management
• Assess
– Respiratory function
– Degree of strength of all muscles involved
• Obser...
Myasthenia Gravis:
Nursing Diagnoses
• Ineffective breathing pattern
• Impaired gas exchange
• Ineffective airway clearanc...
Restless Leg Syndrome
Restless Leg Syndrome
• Etiology and pathophysiology
• Signs/Symptoms
• Diagnostic studies
• Collaborative care
• Nursing ...
Restless Leg Syndrome
• Etiology and pathophysiology
– Characterized by leg paresthesias (burning or
prickling sensation, ...
Restless Leg Syndrome
• Diagnostic studies
– Diagnosis based on history
– Possible associated conditions
• Vitamin and min...
Restless Leg Syndrome
• Collaborative Care
– Treatment of contributing condition
– Education on limiting caffeine, nicotin...
Trigeminal Neuralgia
• Pathophysiology
– Trigeminal neuralgia a/k/a tic douloreux
– 5th cranial nerve affected
– Usually a...
Trigeminal Neuralgia
Trigeminal Nerve
(a/k/a 5th cranial nerve)
Trigeminal nerve sends
sensations of pain, touch,
pressure...
Trigeminal Neuralgia
• Collaborative Management
– Control pain
– Dilantin or Tegretol
– Neurontin
– Local anesthesia
– Mic...
Trigeminal Neuralgia
Nursing Management
• Acute pain
• Imbalanced nutrition
• Anxiety
• Impaired oral mucosa
Amyotrophic Lateral Sclerosis (ALS)
(Lou Gehrig’s Disease)
• Named after 1930s baseball player, Lou Gehrig
• Rapidly progr...
Lou Gehrig’s Disease:
Classic Pattern
• Weakness, atrophy, fasciculation (twitching) of
muscles of the hands and arms
• Co...
Lou Gehrig’s Disease:
Symptoms
• Muscle weakness, wasting and atrophy
• Muscle spasticity and hyperreflexia
• Fasciculatio...
Lou Gehrig’s Disease: Symptoms
• History and neuro exam
• Electromyelogram (EMG) (a/k/a a nerve
conduction study)
• CPK (a...
Lou Gehrig’s Disease (Amyotrophic Lateral
Sclerosis):
Management
• No known treatment or cure (symptomatic)
• PT; OT
• Gas...
Lou Gehrig’s Disease (Amyotrophic Lateral
Sclerosis):
Management
• Assist patient to remain independent
• Limit complicati...
Bell’s Palsy
• Etiology and Pathophysiology
– CN VII (facial)
– Cause is unknown, but reactivation of herpes
simplex virus...
Bell’s Palsy
• (Clinical manifestation, continued)
• Drawing sensation and paralysis on affected
side
• Inability to close...
Bell’s Palsy
• Diagnostic tests
– No specific test
– Exclusion diagnosis…
• Collaborative care
– Prednisone; Zovirax
– Man...
Bell’s Palsy:
Nursing Diagnoses
• Acute pain related to inflammation of CN VII
• Imbalanced nutrition related to inability...
Bell’s Palsy:
Nursing Planning
• Warm-moist heat
• Analgesics as prescribed
• Dark glasses
• Protect from cold
• Artificia...
Guillain-Barre Syndrome
• Etiology and Pathophysiology
– Cell mediated immunologic reaction
– Acute inflammatory polyneuro...
Guillain-Barre Syndrome:
Three Stages
• Initial
– Onset until no further deterioration (usually occurs
about 3 wks after v...
Guillain-Barre Syndrome:
Types
• Ascending
• Descending
• Pure Motor
• Miller-Fisher variant
Guillain-Barre Syndrome:
Ascending
• Most common type
• Weakness and numbess begin in legs
• Paresthesia (numbness; tingli...
Guillain-Barre Syndrome:
Descending
• Weakness progresses downward
• Motor deficits – initial deficitis in the brainstem,
...
Guillain-Barre Syndrome:
Pure Motor
• Identical to ascending GBS, except sensory
signs and symptoms are absent (they have
...
Guillain-Barre Syndrome:
Miller-Fisher Variant
• Opthalmoplegia (paralysis or weakness in
muscle(s) that control the eye) ...
Guillain-Barre Syndrome:
Clinical Presentation
• Recent history of viral infection
• 80% to 90% will have little or no res...
Guillain-Barre Syndrome:
Clinical Presentation
• Respiratory failure attributed to mechanical
failure and fatigue of inter...
Guillain-Barre Syndrome:
Collaborative Management
• Immunotherapy
• Plasmaphoresis
• Respiratory support – frequently elec...
Guillain-Barre Syndrome:
Nursing Diagnoses
• Ineffective breathing pattern: Ineffective
airway exchange; Impaired gas exch...
Spinal Cord Problems
• Etiology and Pathophysiology
– Primary injury
• Usually compression type injury; rarely dura is
pun...
Spinal Cord Trauma
• Mechanisms of injury
– Flexion
– Hyperextension
– Flexion-rotation
– Flexion/extension rotation
– Com...
Spinal Cord Injury Classification
Incomplete Spinal Cord Injury
Anterior Cord Syndrome
May result in loss or impaired
ability to sense pain,
temperature or ...
Incomplete Spinal Cord Injury
Posterior Cord Syndrome
Muscle power; pain; temperature
sensations are preserved.
May have d...
Spinal Cord Trauma
• Complete or incomplete
• Mechanisms of Injury
– Flexion
– Hyperextension
– Flexion/rotation
– Flexion...
Spinal Cord Trauma
• Clinical manifestations
– Respiratory system
– Cardiovascular system
– Urinary system
– GI system
– I...
Spinal Cord Trauma
• Diagnostic tests
– X-ray; CT; MRI (gold standard… CT scan is waste of
time); neurologic exam; possibl...
Spinal Cord Trauma
• Drug therapy: Large doses of prednisone
– Side effects may include UGI bleeding (stress
ulcer)
• Surg...
SCI: Nursing Management / Diagnoses
• Impaired gas exchange R/T diaphragmatic fatigue; paralysis;
retained secretions; as ...
Spinal Cord Injury:
Nursing Diagnoses
• Impaired urinary elimination
• Impaired physical mobility
• Constipation
• Imbalan...
Spinal Cord Injury:
Nursing Diagnoses
• Risk for autonomic dysreflexia R/T stimulated sympathetic
nervous system after spi...
Spinal Cord Injury:
Nursing Diagnoses
• Rehabilitation and Home Care
– Respiratory rehabilitation
– Neurogenic bladder
– N...
Affects of Spinal Cord Injury
Segmental Spinal Cord Level and Function
Cl-C6 Neck flexors
Cl-Tl Neck extensors
C3, C4, C5 ...
Spinal Cord Injury: Functionality of C1, C2, C3
Quadriplegic
Mobility & Movement
Limited head and neck movement depending ...
Spinal Cord Injury:
Functionality of C4 Spinal Cord Injury
Mobility & Movement
Full head and neck movement depending on mu...
Spinal Cord Injury: Functionality of C5
Spinal Cord Injury
Mobility & Movement
Full head and neck movement with good muscl...
Spinal Cord Injury: Functionality of C6
Spinal Cord Injury
Mobility & Movement
Full head and neck movement with good muscl...
Spinal Cord Injury: Functionality of C7 - C8
Spinal Cord Injury
Mobility & Movement
Full head and neck movement with good ...
Spinal Cord Injury: Functionality of T1 - T4
Paraplegic
Mobility & Movement
Full head and neck movement with normal muscle...
Spinal Cord Injury: Functionality of T5 - T9
Spinal Cord Injury
Mobility & Movement
Full head and neck movement with norma...
Spinal Cord Injury: Functionality of T10 - L1
Spinal Cord Injury
Mobility & Movement
Full head and neck movement with norm...
Spinal Cord Injury: Functionality of L2 - S5
Spinal Cord Injury
Mobility & Movement
Full head and neck movement with norma...
Chronic Neurologic Oct 23.pptx - Slide 1
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Chronic Neurologic Oct 23.pptx - Slide 1

  1. 1. Chronic Neurologic Problems Fall 2009
  2. 2. Headache • The most common type of pain experienced by humans • Types – Tension type headache – Migraine headache – Cluster headache
  3. 3. Tension-Type Headache • Characterized by… – Neck and shoulder muscle pain; Bilateral pain at the base of the skull and in the forehead • Etiology and Pathophysiology – Exact cause is unknown – Sometimes difficult to distinguish – Precipitating factors may include: Stress; Hunger; Sleep deprivation; Eyestrain; Withdrawal from caffeine
  4. 4. Migraine Headache • Etiology and Pathophysiology – …episodic familial disorder manifested by unilateral, frontotemporal, throbbing pain in the head which is often worse behind one eye or ear • Clinical manifestations – … often accompanied by sensitive scalp; Anorexia; Photophobia; Nausea with (or without) vomiting
  5. 5. Migraine Headache • Three classifications for migraine headache • Migraines with aura – Aura is a sensation that indicates the onset of a migraine or seizure (develops over several minutes; does not last more than an hour) – Aura may consist of flashing lights; buzzing noises; distorted vision (find out what triggers it) • Migraines without aura – Most are migraines without aura
  6. 6. Migraine Headache • Atypical migraine (more assoc w/ teens & 20 yr olds) – Less common – Associated with menstrual periods – Includes cluster headaches • Neuroimaging recommended for persons older than 50 years of age with new onset of headaches When and Why? (worrisome… MRI might be test of choice) • MRI is gold standard for migraine, but CT scan is much cheaper.
  7. 7. Stages of a Migraine Headache • Prodrome phase (specific symptoms including food cravings; mood changes) • Aura phase (visual changes; diplopia [double vision]; flashing lights) • Headache phase: few hours to a few days • Termination phase (intensity decreases) • Postprodrome phase (fatigue; muscle pain; irritable)
  8. 8. Cluster Headache • Less frequent than migraines • More common in men between 20 and 50 years of age • Definitive cause of headache is unknown • May be related to hypothalamic hyperactivity • Onset is associated with relaxation, napping, or rapid eye movement (REM) sleep • Pain is unilateral, oculotemporal or oculofrontal; Excruciating, boring and non-throbbing type
  9. 9. Cluster Headache • Intense pain felt deep in and around the eye (may radiate to the ear and neck) • Ipsilateral (same side) tearing of the eye; runny rhinorrhea (runny nose) or congestion; ptosis (drooping eyelid); miosis (abnormal constriction of pupils) • Headaches occur every 8 to 12 hours, up to 24 hours a day at the SAME TIME for 6 to 8 weeks • Remission follows for 9 months to 1 year • Duration of headache is usually 10 to 45 minutes • (tearing, runny nose might be the way to tell difference between cluster 7 migraine)
  10. 10. Headaches – Other Types • Can be first symptom of a more serious illness • Can be accompany subarachnoid hemorrhage; brain tumors; other intracranial masses; arteritis; vascular abnormalities; trigeminal neuroalgia (intense pain around the eyes, lips, nose, scalp, forehead and jaw); diseases of the eyes, nose, and teeth; and systemic illness
  11. 11. Headaches • Collaborative Care for Headaches – Drug therapy • Tension-type headache – Acetaminophen and NSAIDs • Migraine headache – Acetaminophen and NSAIDs (Naproxen) effective for mild migraine pain – Abortive therapy (aura phase) and Preventative therapy (with history of migraines 2 to 3 times/month) • Cluster headache – Drug therapy same as for migraine headache
  12. 12. Headaches: Nursing Management • Nursing assessment • Nursing diagnoses • Planning • Nursing Implementation • Evaluation
  13. 13. Headaches: Nursing Diagnoses • Acute pain related to lack of knowledge of pain control techniques or methods to prevent headaches • Disturbed energy field related to disharmony • Ineffective management of therapeutic regimen related to lack of knowledge, identification and elimination of aggravating factors
  14. 14. Chronic Neurologic Disorders Other
  15. 15. Epilepsy • “To be seized from a force within” • Chronic condition characterized by recurrent paroxysmal (sudden attack)episodes of disturbance in – Skeletal muscle function – Sensation – Autonomic visceral function often lose bowel & bladder control – Behavior and consciousness: some have aura & may have behavioral change… don’t lose consciousness, but may become drowsy or stuporous • Amount of time between varies, usually there is repetition of activity • “pretty important” • Can be primary disease or a symptom of a disease… learn diff types of epilepsy & types of seizures • Don’t say grand mal any more… it is generalized or tonic clonic seizure.
  16. 16. Epilepsy • A symptom of CNS irritation, excessive and abnormal neuronal discharges • Present as a manifestation of disease in approximately 50 other diseases • Epilepsy in a nutshell: Epilepsy is a common neurological disorder characterized by recurrent seizures • Caused by a brief disruption of electrical activity in the brain
  17. 17. Epilepsy • Affects 2 – 4 million people* • Not accurate* – Not reportable – Individuals not likely to admit to condition Why?
  18. 18. Epilepsy • Most common age groups: – Birth to 2 years – 5-7 years – Early puberty (especially girls) • 90% of all patients experience first seizure prior to age 20 • Genetic tendency toward cerebral dysrrhythmias
  19. 19. Epilepsy • Cerebral epilepsy-cerebral lesions account for activity, usually due to… – Birth injuries (Example: Cerebral palsy) – Infectious disorders (Example: meningitis… once treated, the seizure disorder will go away… takes a long time to treat… on antiepileptic meds while treating for meningitis) – Circulation disorders (Example: stroke) – Cerebral trauma (Example: TBI) – Neoplasms (Recall prior slide!)
  20. 20. Epilepsy • Biochemical epilepsy – biochemical disorders that include epilepsy as a clinical feature – Alcohol ingestion/drug overdose (barbiturates, high doses, can be a cause of a seizure disorder) – Medications (Overdose or withdrawal. Examples: Antidepressants, Antipsychotics, PNC in high doses, Lithium) – Electrolyte imbalance (Example: Altered levels of sodium magnesium; calcium) – Vitamin deficiency – Diabetes mellitus (Example: Hypoglycemia; Hypercalcemia) – Pregnancy and/or menstruation
  21. 21. Epilepsy • Post traumatic epilepsy – from previously sustained cerebral injuries, few prior to 2 months or after 5 years – Head injuries – Birth injuries • Idiopathic epilepsy – no identifiable cause
  22. 22. Seizures: Terms to Remember • Prodromal (Early warning of impending attack) • Aura (Visual disturbances… can be any of the 5 senses…; buzzing sounds) • Ictus (The event; i.e., seizure) – Tonus (Maintained contraction r/t bombardment of motor impulses) – Clonus (Contraction/relaxation of muscles, wild muscle movement) • Postictal (Exhaustion): confusion common
  23. 23. Seizure Classification • Generalized – bilaterally symmetric and without local onset – Tonic-clonic seizures (Type most commonly associated with epilepsy; Generalized seizure) – Typical absence seizures (Stares into space without twitching; Lasts for seconds) – Atypical absence seizures (Stares but is somewhat responsive) – Other types of generalized seizures (Associated with AIDS; Acute infection; Alcohol or drug use)
  24. 24. Seizure Classification • Partial-focal in nature, may become generalized – Simple/partial: No loss of consciousness • Focal (or local) motor or sensory: can begin in one part of the cebrum & spread. Pt usually maintains level of consciousnesss… may report aura or feeling of déjà vu. Odd movement, twitching of hand or tapping of foot… may also have increase in heart rate (sypathetic response, become flush) • Complex partial seizure: loss of consciousness, 1 to 3 min. Aka psychomotor seizures or temporal lobe. Often a motor response. • Jacksonian • Pseudoseizure: don’t see them very often; no aura, don’t lose bladder function, won’t fall out of chair, don’t allow themselves to be harmed but will allow themselves to have the movement seen in a tonic clonic seizure. May be attention getting… could be the beginning of bad things that are going to happen.
  25. 25. Clinical Manifestations • Aura • Tonic-hypertonic-clonic phase – Loss of consciousness – Bowel and bladder incontinence – Tachycardia – Diaphoresis – Warm skin – Pallor, flushing, cyanosis • Post-ictal phase
  26. 26. Epilepsy • Complications – Status epilepticus (life threatening, need ER & immediate meds… valium/diazapem and ativan, can last 5 min or longer, w/ each event it increases in intensity – Psychosocial • Diagnostic Studies – Accurate description of seizures; EEG; CT; MRI – Rule out metabolic disorders
  27. 27. Epilepsy : Status epilepticus • Life threatening • Brain in a state of persistent seizure • Continuous seizure lasting more than 30 minutes or recurrent seizures w/o regaining consciousness between seizures for > 30 minutes • May be neuron damage at 5 minutes Why? • 911 for seizure lasting > 5 minutes
  28. 28. Epilepsy: Collaborative Care • 75% can be managed successfully with anticonvulsant medications (great list in the book… tegretol, dilantin, phenobarbitol, kepra [newer w/ fewer side effects], • Medications will manage the symptoms, but will not cure the condition
  29. 29. Epilepsy: Medications • Generalized and Partial seizures – Phenytoin (Dilantin); Side effects: gingival hyperplasia; drug toxicity – Carbamazepine (Tegretol) – Phenobarbital – Divalproex (Depakote) – Gabapentin (Neurontin)
  30. 30. Epilepsy: Medications • Absent, Akinetic – Klonopin; Zarotin • Status Epilepticus – Ativan (benzodiazepine) and Valium
  31. 31. Epilepsy: Surgical Intervention • Remove focus: if alcohol w/drawal is causing seizure, then remove the problem • Prevent spread – Remove lobe, cortex – Separate hemispheres at corpus callosum – (similar to WPW ablation on heart, but done in brain)
  32. 32. Immediate Seizure Management • During Seizure – Provide privacy – Maintain airway (don’t put anything in mouth, maybe put them on side if able) – Ease to floor; protect from injury • After Seizure – Position on side – Allow time to sleep – Re-orient individual
  33. 33. When Observing a Seizure • Prodromal – Where there any warning signs? • Ictus – Where did it begin and how did it proceed? – Describe movements – How long? – Changes in pupil size? – Incontinence? – LOC?
  34. 34. When Observing a Seizure • Post-ictal – Behavior after the seizure (describe) – Any paralysis or weakness following the seizure? – Did the individual sleep? – After the seizure, document, do vitals, etc…
  35. 35. Multiple Sclerosis • Chronic, progressive, degenerative disorder of the CNS characterized by disseminated demyelination and inflammation of nerve fibers of the brain and spinal cord • MS in a nutshell: Results from progressive demyelination of the white matter of the brain and spinal cord; Hard yellow plaques of scar tissue form (gliosis); Damage to underlying axon fiber so nerve conduction is disrupted; irreversible as disease progresses
  36. 36. Multiple Sclerosis Etiology and Pathophysiology • Cause is unknown • Related to infectious, immunologic, and genetic predisposition • Multiple genes confer susceptibility to MS • Disease usually affects young to middle-aged adults,= with onset between 15 and 50 years of age • Women are affected more than men
  37. 37. Multiple Sclerosis Etiology and Pathophysiology • Possibility that the association between pathogenetic agents and MS is random and there is no cause-and-effect relationship
  38. 38. Multiple Sclerosis Etiology and Pathophysiology • Possible precipitating factors include: – Infection – Physical injury – Emotional stress – Excessive fatigue – Pregnancy – Poor state of health
  39. 39. Multiple Sclerosis Etiology and Pathophysiology • Primary neuropathologic condition is an autoimmune disease orchestrated by autoreactive T-cells – Remember “T” cells? Helper T cells and Killer T cells. Helper T cells stimulate B cells to make antibodies, and help killer cells develop. Killer T cells kill the body’s own cells that have been invaded by viruses or bacteria. • Characterized by chronic inflammation, demyelination (damage to myelin sheath of neurons) and gliosis (scar formation) in the CNS
  40. 40. Multiple Sclerosis Etiology and Pathophysiology • Initially triggered by a virus in a genetically susceptible individual • Subsequent antigen-antibody reaction leads to demyelination of axons
  41. 41. Multiple Sclerosis Etiology and Pathophysiology • Disease process consists of loss of myelin, disappearance of oligodendrocytes, and proliferation of astrocytes • Changes result from plaque formation with plaques scattered throughout the CNS
  42. 42. Multiple Sclerosis Etiology and Pathophysiology • Initially the myelin sheaths of the neurons in the brain and spinal cord are attacked, but the nerve fiber is not affected • Patient may complain of noticeable impairment of function • Myelin can regenerate, and symptoms disappear, resulting in a remission
  43. 43. Multiple Sclerosis Etiology and Pathophysiology • Myelin can be replaced by glial scar tissue • Without myelin, nerve impulses slow down • With destruction of axons, impulses are totally blocked • Results in permanent loss of nerve function
  44. 44. Multiple Sclerosis Clinical Presentation • Vague symptoms occur intermittently over months and years • Disease may not be diagnosed until long after the onset of the first symptom • 1st symptoms: sensory symptoms of the arms/legs; unilateral vision loss; slowly progressive motor deficit
  45. 45. Multiple Sclerosis Clinical Presentation • Characterized by – Chronic, progressive deterioration in some – Remissions and exacerbations in others • Motor manifestations – Weakness or paralysis of limbs, trunk, and head – Foot drop; pressure ulcers – Scanning speech (slurred, stretching of words); dysarthria (motor speech disorder/poor articulation) – Spasticity of muscles – Tremor
  46. 46. Multiple Sclerosis Clinical Presentation: Sensory • Numbness and tingling • Blurred vision;diplopia (double vision) • Vertigo and tinnitus • Decreased hearing • Chronic neuropathic pain
  47. 47. Multiple Sclerosis Clinical Presentation: Cerebellar • Nystagmus (Involuntary movement of the eye) • Ataxia (Inability to coordinate muscle movement) • Dysarthria (motor speech disorder, i.e., slurred speech) • Dysphagia (Difficulty swallowing)
  48. 48. Multiple Sclerosis Clinical Presentation: Emotional • Anger • Depression • Apathy • Inattentiveness • Euphoria
  49. 49. Multiple Sclerosis Clinical Presentation: Other • Bowel and bladder functions may be impaired – Constipation – Spastic bladder; small capacity for urine results in incontinence – Inability of sphincter to open – Flaccid bladder; large capacity for urine and no sensation to urinate
  50. 50. Multiple Sclerosis Clinical Presentation (Other) • Sexual dysfunction can occur in MS - erectile dysfunction - decreased libido - painful intercourse - decreased lubrication
  51. 51. Multiple Sclerosis: Diagnostic Studies • Based primarily on history, clinical presentation, and presence of multiple plaques over time measured by MRI • Certain laboratory tests are used as adjuncts to clinical exam – CSF analysis: high lymphocytes and monocytes (lumbar puncture, breakdown of meylin is breakdown of protein, should not be protein in CSF)
  52. 52. Multiple Sclerosis: Collaborative Care • Drug therapy – Corticosteroids (maintiain stability of cell wall so it doesn’t break down so fast & antiinflammatory effect… but you can’t stay on them forever) • Treat acute exacerbations by reducing edema and inflammation at the site of demyelination • Does not affect the ultimate outcome or degree of residual neurologic impairment from exacerbation of disease
  53. 53. Multiple Sclerosis: Collaborative Care • Immunosuppressive Therapy – Potential benefits are counterbalanced against potentially serious side-effects (even some chemo drugs can be used to slow down the progression of the disease, often can live a pretty normal life for a long time… 25 years) • Immunomodulators – Interferon ß-1b (Betaseron) - Interferon ß-1a (Avonex, Rebif)
  54. 54. Multiple Sclerosis: Collaborative Care • Antispasmotics (any muscle, bladder, etc…) • CNS stimulants • Anticholinergics and/or cholinergics • Tricyclic antidepressants and anti-seizure medications (unusual for anti-seizure meds) • These are symptom relief meds
  55. 55. Multiple Sclerosis: Collaborative Care • Surgery (for patients with severe tremor) • Dorsal-column electrical stimulation (electrodes placed in the subdural extra arachnoid space over the center of the thoracic spinal cord – result is increased motor/sensory function) • Intrathecal baclofen pump (Baclofen is a muscle relaxant used to decrease spasticity in MS; SCI; Other neurologic problems)
  56. 56. Multiple Sclerosis: Collaborative Care • Physical therapy helps… – Relieve spasticity – Increase coordination – Trains the client to substitute unaffected muscles for impaired ones
  57. 57. Multiple Sclerosis: Collaborative Care • Nutritional therapy includes… – Megavitamins and diets consisting of low-fat, gluten-free, food, and raw vegetables – High-protein diet with supplementary vitamins is often prescribed
  58. 58. Multiple Sclerosis: Nursing Assessment • Health history – Viral infections or vaccinations – Residence in cold or temperate climates – Physical and emotional stress – Medications – Elimination problems – Weight loss, dysphagia
  59. 59. Multiple Sclerosis: Nursing Diagnoses • Impaired physical mobility • Dressing/grooming self-care deficit • Risk for impaired skin integrity • Impaired urinary elimination pattern • Sexual dysfunction • Interrupted family processes
  60. 60. Multiple Sclerosis: Nursing Plan of Care • Maximize neuromuscular function • Maintain independence in activities of daily living for as long as possible • Optimize psychosocial well-being • Adjust to the illness • Reduce factors that precipitate exacerbation of symptoms
  61. 61. Multiple Sclerosis: Nursing Implementation • Help patient identify triggers and develop ways to avoid them or minimize their effects • Reassure patient during diagnostic phase • Assist patient in dealing with anxiety caused by diagnosis • Prevent major complications of immobility
  62. 62. Multiple Sclerosis: Nursing Implementation • Focus teaching on building general resistance to disease – Avoiding fatigue; extremes of hot and cold; exposure to infection • Teach good balance of exercise and rest, nutrition, avoidance of hazards of immobility
  63. 63. Multiple Sclerosis: Nursing Implementation • Teach self-catheterization if necessary • Teach adequate intake of fiber to aid in regular bowel habits
  64. 64. Parkinson’s Disease • Disease of basal ganglia characterized by… – Slowing down in the initiation and execution of movement – Increased muscle tone (no atrophy usually) – Tremor at rest – Impaired postural reflexes
  65. 65. Parkinson’s Disease: Etiology and Pathophysiology • Pathologic process involves degeneration of dopamine-producing neurons in substantia nigra of the basal ganglia • Disrupts dopamine-acetylcholine balance in basal ganglia (decreased acetylcholine & dopamine) • Symptoms of the disease do not occur until 80% of neurons in the substantia nigra (basal ganglia, lie near the lateral ventricles, when stimulated they release the dopamine) are lost
  66. 66. Parkinson’s Disease • Diagnosis increases with age • Peak onset in the 6th decade of life • Onset before age 50 is likely related to genetic defect • More common in men: ratio is 3:1 • Other causes include hydrocephalus; hypoxia; infections; stroke; tumor; and trauma (i.e., injury to the brain)
  67. 67. Parkinson’s Disease • Clinical Presentations (goes from stage 1 to stage 5… book gives good description of stages) – Symptoms may involve only one side of the body initially – Beginning stages may involve only mild tremor, slight limp or decreased arm swing – Later stages may show shuffling, propulsive gait with arms flexed, loss of postural reflexes – Never progresses to complete paralysis
  68. 68. Parkinson’s Disease • Classic triad of clinical symptoms include – Tremor – Rigidity – Bradykinesia (slow movement) – (proprioception, postural instability, loosing awareness of where their body is at all times)
  69. 69. Parkinson’s Disease • Tremors – More prominent at rest and aggravated by emotional stress or increased concentration – Described as “pill rolling” because thumb and forefinger appear to move in rotary fashion – Tremor can involve diaphragm, tongue, lips and jaw – Benign essential tremor, which occurs during voluntary movement, has been misdiagnosed as Parkinson’s disease
  70. 70. Parkinson’s Disease • Rigidity (2nd classic symptom) – Caused by sustained muscle contraction and consequently elicits: • Complaints of soreness • Feeling tired and achy • Pain in the head, upper body, spine, or legs • Rigidity is typified by a jerky-quality when the joint is moved • Rigidity is similar to intermittent catches in the movement of a cogwheel (“cogwheel rigidity”) • Inhibits the alternating contraction and relaxation in opposing muscle groups, thus slowing movement
  71. 71. Parkinson’s Disease • Bradykinesia – Slowing down in initiation and execution of movement-lean forward to initiate ambulation – Evident in loss of automatic movements • Blinking • Swinging of arms while walking • Swallowing of saliva • Self-expression with facial movements (“masked facies”)
  72. 72. Parkinson’s Disease: Complications • Caused by progressive deterioration and loss of spontaneity of movement • Dysphagia can lead to malnutrition or aspiration • Debilitation may lead to pneumonia, UTI, and skin breakdown • 30-40% have dementia • Orthostatic hypotension may occur along with loss of postural reflexes • Falls and other injuries can result
  73. 73. Parkinson’s Disease: Complications • Side effects from drugs, particularly levodopa, include… – Dyskinesia (involuntary movement) – Hallucinations – Orthostatic hypotension – Weakness – Akinesia (without movement or much movement)
  74. 74. Parkinson’s Disease: Diagnostic Tests • No specific tests • Diagnosis is based on history and clinical features – Firm diagnosis can be made when at least 2 of 3 characteristics of classic triad -tremor, rigidity and bradykinesia (slowness of movement)- are present – Ultimate confirmation of diagnosis is a positive response to antiparkinsonian drugs
  75. 75. Parkinson’s Disease: Collaborative Care • Drug therapy – – Aimed at correcting imbalances of neurotransmitters within the CNS – Enhance or release supply of dopamine – Antagonize or blocks the effect of over-active cholinergic neurons in the striatum
  76. 76. Parkinson’s Disease: Collaborative Care • Levodopa with carbidopa (Sinemet) is often the first drug used – Precursor of dopamine and crosses the blood/brain barrier – Converted to dopamine in the basal ganglia – Carbidopa inhibits an enzyme that breaks down levodopa before it reaches the brain
  77. 77. Parkinson’s Disease: Collaborative Care • Effectiveness of Sinemet can wear off after a few years of therapy – Initiation of therapy is with a dopamine receptor agonist (an agonist is site specific drug) instead (Parlodel) • Anticholinergics are also used in the management of Parkinson’s disease (Artane, Cogentin) – Decreases activity of acetylcholine
  78. 78. Parkinson’s Disease: Collaborative Care • Antihistamines with anticholinergic or beta- adrenergic blockers are used to manage tremors • Antiviral agent amantadine is effective though exact mechanism is unknown (Symmetryl) • As disease progresses, combination therapy is often required • Excessive amounts of dopaminergic drugs can lead to paradoxical intoxication (i.e., excessive drug load)
  79. 79. Parkinson’s Disease: Collaborative Care • Surgical treatment – Procedures aimed at relieving symptoms in patients who are unusually unresponsive to drug therapy • Ablation surgery – Stereotactic ablation of areas in the thalamus, globus pallidus, and subthalmic nucleus (unilateral pallidotomy improves tremor and dyskinesia on one side of the body; deep brain stimulation preferable)
  80. 80. Parkinson’s Disease: Collaborative Care • Deep brain stimulation – Involves placing an electrode in either the thalamus, globus pallidus, and subthalmic nucleus – Connected to a generator placed in the upper chest – Device is programmed to deliver specific current to target brain location – Is adjustable and reversible
  81. 81. Parkinson’s Disease: Collaborative Care • Transplantation of fetal neural tissue into the basal ganglia provides dopamine producing cells in the brains of patients – Still experimental – Controversial
  82. 82. Parkinson’s Disease: Collaborative Care • Nutritional therapy: – Malnutrition and constipation can be serious consequences – Patients with dysphagia and bradykinesia need food that is easily chewed and swallowed – Adequate roughage – Several small meals to prevent fatigue – Provide ample time to avoid frustration – Levodopa can be impaired by protein ingestion
  83. 83. Parkinson’s Disease: Nursing Assessment/Management • History – CNS trauma – Cerebrovascular disorders – Exposure to metals (23 types of heavy metals) – Encephalitis – Medications such as tranquilizers, amphetamines, methyldopa – Excessive salivation; dysphagia; weight loss
  84. 84. Parkinson’s Disease: Nursing Assessment / Management • History, continued – Difficulty initiating movements; falls; loss of dexterity – Constipation; incontinence – Diffuse pain in head, shoulders, neck, back, arms, legs, and hips – Depression; mood swings; hallucinations
  85. 85. Parkinson’s Disease: Nursing Diagnoses • Impaired physical mobility • Imbalanced nutrition: less than body requirements • Impaired verbal communication • Deficient diversion activity • Risk for falls
  86. 86. Parkinson’s Disease: Nursing Management/Planning • Maximize neurologic function (Pharm therapy as prescribed; Pilates, which teaches balance and control of body) • Maintain independence in ADLs for as long as possible • Optimize psychosocial well-being
  87. 87. Parkinson’s Disease: Nursing Management/Implementation • Teach maintenance of good health, independence, and avoidance of complications • Promotion of physical exercise and well- balanced diet – Specific exercises to strengthen muscles involved with speaking and swallowing – Healthy diet – fruits, vegetables, eggs, some cereal
  88. 88. Parkinson’s Disease: Nursing Management/Implementation • Problems secondary to bradykinesia can be alleviated by – Consciously thinking about stepping over a line on the floor – Lifting toes when stepping – One step back and… – Two steps forward
  89. 89. Parkinson’s Disease: Nursing Management/Implementation • Getting out of chair by using arms and placing the back legs on small blocks • Remove rugs and excess furniture • Simplify clothing from buttons and hooks • Elevated toilet seat
  90. 90. Myasthenia Gravis • A chronic, progressive disease of muscular weakness caused by a defect at the myoneural junction (The synaptic connection of the axon of a motor neuron with a muscle fiber) • Etiology - possibly autoimmune – Antibodies attack acetylcholine receptors→decreased acetylcholine→decreased muscle contraction • Gradual onset • Peak onset 20 – 30 years of age
  91. 91. Myasthenia Gravis: Hallmarks of the Disease • Weakness of certain voluntary muscles • Improvement of muscle strength at rest • Dramatic improvement of muscle strength with anticholinesterase drugs
  92. 92. Myasthenia Gravis: Symptoms • Muscles of the eye affected first • Facial, masticatory, speech and neck muscles are next • Muscles of fine hand movements • Intercostal muscles • Myasthenia crisis: acute exacerbation (breathing and throat muscle weakness)
  93. 93. Myasthenia Gravis: Diagnosis • Based on history of weakness in certain muscle groups which improve with rest • Tensilon test (Tensilon extends muscle stimulation, and briefly improves strength. Muscle strength increased as a result of Tensilon injection yields a probable diagnosis of MG) • Serum antibodies to acetycholine – Usually elevated in 80-90% of patients
  94. 94. Myasthenia Gravis: Medical Management • Anticholinesterase drugs facilitate impulse across neuromuscular junctions – Neostigmine; Pyridostigmine • Corticosteroids make symptoms worsen prior to improvement and remission • Plasmapheresis – Washes acetylcholine receptor antibodies from plasma (also done for guillian barre… can be done over & over…)
  95. 95. Myasthenia Gravis: Nursing Management • Assess – Respiratory function – Degree of strength of all muscles involved • Observe for – Signs and symptoms of pneumothorax (as result to diaphragm & other intercostal muscles being affected) – Unpredictable responses to drugs • Patient teaching – Re exacerbations of the disease
  96. 96. Myasthenia Gravis: Nursing Diagnoses • Ineffective breathing pattern • Impaired gas exchange • Ineffective airway clearance • Activity intolerance • Impaired verbal communication • Imbalanced nutrition • Disturbed body image
  97. 97. Restless Leg Syndrome
  98. 98. Restless Leg Syndrome • Etiology and pathophysiology • Signs/Symptoms • Diagnostic studies • Collaborative care • Nursing management
  99. 99. Restless Leg Syndrome • Etiology and pathophysiology – Characterized by leg paresthesias (burning or prickling sensation, “crawing-like”) associated with a strong urge to move – 20 million Americans affected • Signs/Symptoms – Worse in the evening when at rest
  100. 100. Restless Leg Syndrome • Diagnostic studies – Diagnosis based on history – Possible associated conditions • Vitamin and mineral deficiencies • Anemias • Polyneuropathies • Diabetes type II • Pregnancy • Peripheral nerve disease • Pinched nerves • Lumbar surgical procedures • Renal failure • Substances, i.e., caffeine, alcohol beta-blockers • Parkinson’s disease (Ignatavicius & Workman, 2006)
  101. 101. Restless Leg Syndrome • Collaborative Care – Treatment of contributing condition – Education on limiting caffeine, nicotine and alcohol – Routine bedtime – No strenuous exercise 2-3 hours before bedtime • Nursing Management – Education (Ignatavicius & Workman, 2006)
  102. 102. Trigeminal Neuralgia • Pathophysiology – Trigeminal neuralgia a/k/a tic douloreux – 5th cranial nerve affected – Usually affects people > 50 years of age – Female to male ratio 2:1 – Unilateral facial pain (intense spasms) – Provoked by minimal stimulation of a trigger zone – Pain described as… • Sharp; shooting; burning; jabbing; piercing; no motor or sensory deficits; usually life-long from onset; symptoms improve with aging (Ignatavacius & Workman, 2006)
  103. 103. Trigeminal Neuralgia Trigeminal Nerve (a/k/a 5th cranial nerve) Trigeminal nerve sends sensations of pain, touch, pressure, temperature to the brain from the face, jaw, gums, forehead and around the eyes (Gama Knife Center, 2008)
  104. 104. Trigeminal Neuralgia • Collaborative Management – Control pain – Dilantin or Tegretol – Neurontin – Local anesthesia – Microcirculation decompression
  105. 105. Trigeminal Neuralgia Nursing Management • Acute pain • Imbalanced nutrition • Anxiety • Impaired oral mucosa
  106. 106. Amyotrophic Lateral Sclerosis (ALS) (Lou Gehrig’s Disease) • Named after 1930s baseball player, Lou Gehrig • Rapidly progressive, degenerative, fatal disease (generally don’t live beyond 5 yrs past diagnosis). • Destruction of motor cells in the anterior grey horns of the spinal cord • Unknown etiology (no known cause, cure, treatment)
  107. 107. Lou Gehrig’s Disease: Classic Pattern • Weakness, atrophy, fasciculation (twitching) of muscles of the hands and arms • Converts to spastic paralysis of the limbs (contractures) • Sensory changes are not present (generally mentally they are completely fine)
  108. 108. Lou Gehrig’s Disease: Symptoms • Muscle weakness, wasting and atrophy • Muscle spasticity and hyperreflexia • Fasciculations • Fatigue • Dyspnea • Brain-stem signs (atrophy of tongue)
  109. 109. Lou Gehrig’s Disease: Symptoms • History and neuro exam • Electromyelogram (EMG) (a/k/a a nerve conduction study) • CPK (also called creatinine kinase) elevated • (CPK found in muscle and brain cells) • Myelogram (contrast x-ray) to rule out other conditions
  110. 110. Lou Gehrig’s Disease (Amyotrophic Lateral Sclerosis): Management • No known treatment or cure (symptomatic) • PT; OT • Gastrostomy tube • Ongoing counseling for patient and family (teaching) • Drug therapy – Rilutek (specific for ALS, will help slow the progression of the disease)
  111. 111. Lou Gehrig’s Disease (Amyotrophic Lateral Sclerosis): Management • Assist patient to remain independent • Limit complications • Prepare for discharge and crisis • Provide emotional and psychological support • Depression is common • Referral to community resources
  112. 112. Bell’s Palsy • Etiology and Pathophysiology – CN VII (facial) – Cause is unknown, but reactivation of herpes simplex virus may be implicated • Clinical manifestation – Maximum paralysis evident within 48 hours for half of those affected; within 5 days for others
  113. 113. Bell’s Palsy • (Clinical manifestation, continued) • Drawing sensation and paralysis on affected side • Inability to close eyes, smile, grimace, wrinkle forehead • Face is mask-like and sags • Impaired taste
  114. 114. Bell’s Palsy • Diagnostic tests – No specific test – Exclusion diagnosis… • Collaborative care – Prednisone; Zovirax – Management of neurological deficits – Psychosocial support
  115. 115. Bell’s Palsy: Nursing Diagnoses • Acute pain related to inflammation of CN VII • Imbalanced nutrition related to inability to chew • Risk for injury – corneal abrasion related to inability to blink • Disturbed body image related to change in appearance related to facial muscle weakness
  116. 116. Bell’s Palsy: Nursing Planning • Warm-moist heat • Analgesics as prescribed • Dark glasses • Protect from cold • Artificial tears • Tape eyelids at night
  117. 117. Guillain-Barre Syndrome • Etiology and Pathophysiology – Cell mediated immunologic reaction – Acute inflammatory polyneuropathy – Incidence of 1.7 per 100,000 – Progressive disorder that affects the motor component of the peripheral nerves – Demyelination (myelin around axons is destroyed… pt has had some type of infection to set it off, auto-immune problem), edema and inflammation
  118. 118. Guillain-Barre Syndrome: Three Stages • Initial – Onset until no further deterioration (usually occurs about 3 wks after viral infection) (1-3 weeks) • Plateau – Little change (several days to 2 weeks) (if caught • Recovery – Coincides with myelination and axonal regeneration (4-6 months)
  119. 119. Guillain-Barre Syndrome: Types • Ascending • Descending • Pure Motor • Miller-Fisher variant
  120. 120. Guillain-Barre Syndrome: Ascending • Most common type • Weakness and numbess begin in legs • Paresthesia (numbness; tingling), hypotonia (abnormally low muscle tone), areflexia (absence of neurologic reflexes) • Respiratory function – insufficiency occurs in 50% of patients
  121. 121. Guillain-Barre Syndrome: Descending • Weakness progresses downward • Motor deficits – initial deficitis in the brainstem, cranial nerves, sternocleidomastoid muscle • Sensory deficits – numbness occurs distally, more often in the hands than in the feet • Paresthesia, hypotonia, and areflexia • Rapid respiratory involvement
  122. 122. Guillain-Barre Syndrome: Pure Motor • Identical to ascending GBS, except sensory signs and symptoms are absent (they have weakness & paralysis, but no numbness or tingling) • May be a mild form of ascending GBS • Muscle pain is generally not present
  123. 123. Guillain-Barre Syndrome: Miller-Fisher Variant • Opthalmoplegia (paralysis or weakness in muscle(s) that control the eye) (CN 3, 4 & 6 affected) • Areflexia • Severe ataxia • Normal motor strength • Intact sensory function
  124. 124. Guillain-Barre Syndrome: Clinical Presentation • Recent history of viral infection • 80% to 90% will have little or no residual disability • GBS is characterized by muscle weakness and areflexia • Symptoms tend to be symmetrical and ascending from legs to trunk and arms
  125. 125. Guillain-Barre Syndrome: Clinical Presentation • Respiratory failure attributed to mechanical failure and fatigue of intercostals and diaphragm • If cranial nerves are involved the facial (VII) is most common • GBS does not affect level of consciousness, cognitive function, or pupillary signs • Diagnosis is based upon clinical picture
  126. 126. Guillain-Barre Syndrome: Collaborative Management • Immunotherapy • Plasmaphoresis • Respiratory support – frequently elective intubation • Supportive treatment
  127. 127. Guillain-Barre Syndrome: Nursing Diagnoses • Ineffective breathing pattern: Ineffective airway exchange; Impaired gas exchange • Impaired physical mobility • Self-care deficit • Impaired verbal communication • Anxiety; Anticipatory grieving
  128. 128. Spinal Cord Problems • Etiology and Pathophysiology – Primary injury • Usually compression type injury; rarely dura is punctured – Secondary injury • Edema related to inflammatory response→cascade of events→tissue hypoxia
  129. 129. Spinal Cord Trauma • Mechanisms of injury – Flexion – Hyperextension – Flexion-rotation – Flexion/extension rotation – Compression
  130. 130. Spinal Cord Injury Classification
  131. 131. Incomplete Spinal Cord Injury Anterior Cord Syndrome May result in loss or impaired ability to sense pain, temperature or touch below the level of injury Central Cord Syndrome Usually results in loss of function in the arms, but some leg movement remains; May have some control over bladder and bowel. Some recovery is possible starting in the legs and moving up (Apparelyzed, 2009)
  132. 132. Incomplete Spinal Cord Injury Posterior Cord Syndrome Muscle power; pain; temperature sensations are preserved. May have difficulty coordinating movement of limbs Brown Séquard Syndrome Pain and temperature sensations may be preserved; has impaired or lost movement on the injured side. Opposite side of injury will have normal movement, but pain and temperature sensation will be impaired or lost. (Apparelyzed, 2009)
  133. 133. Spinal Cord Trauma • Complete or incomplete • Mechanisms of Injury – Flexion – Hyperextension – Flexion/rotation – Flexion/extension/rotation – Compression
  134. 134. Spinal Cord Trauma • Clinical manifestations – Respiratory system – Cardiovascular system – Urinary system – GI system – Integumentary system – Thermoregulation – Metabolic needs – Peripheral vascular problems
  135. 135. Spinal Cord Trauma • Diagnostic tests – X-ray; CT; MRI (gold standard… CT scan is waste of time); neurologic exam; possibly angiogram • Collaborative care – Non-operative stabilization – ABCs! (always critical) – Stabilized; immobile; trach (+ halo); oxygen; maintain heart rate (atropine); blood pressure (dopamine) – UA catheter; NG – DVT Prevention; stress ulcer prevention; – Temperature control
  136. 136. Spinal Cord Trauma • Drug therapy: Large doses of prednisone – Side effects may include UGI bleeding (stress ulcer) • Surgical therapy – Cervical immobilization – halo – Decompression laminectomy
  137. 137. SCI: Nursing Management / Diagnoses • Impaired gas exchange R/T diaphragmatic fatigue; paralysis; retained secretions; as evidenced by (AEB) decreased PO2; adventitious breath sounds; decreased respiratory rate; respiratory fatigue or distress • Decreased cardiac output R/T venous pooling of blood; bradycardia; immobility; AEB hypotension, restlessness; pulmonary edema • Altered (spinal cord) tissue perfusion • Impaired skin integrity
  138. 138. Spinal Cord Injury: Nursing Diagnoses • Impaired urinary elimination • Impaired physical mobility • Constipation • Imbalanced nutrition: less than body requirements • Disturbed body image • Interrupted family processes • Risk for ineffective coping
  139. 139. Spinal Cord Injury: Nursing Diagnoses • Risk for autonomic dysreflexia R/T stimulated sympathetic nervous system after spinal shock resolves as evidenced by severe headache, hypertension, bradycardia, nasal stuffiness, flushing, sweating above the level of injury, feeling of apprehension related to noxious stimulation (i.e., distended bladder, fecal impaction, tactile stimulation) – Interventions: remove noxious stimulation – Antihypertensive meds, reverse Trendelenburg or sitting upright – Patient teaching on prevention, recognition, treating
  140. 140. Spinal Cord Injury: Nursing Diagnoses • Rehabilitation and Home Care – Respiratory rehabilitation – Neurogenic bladder – Neurogenic bowel – Neurogenic skin – Sexuality – Grief and depression – Long term adaption of patient and family
  141. 141. Affects of Spinal Cord Injury Segmental Spinal Cord Level and Function Cl-C6 Neck flexors Cl-Tl Neck extensors C3, C4, C5 Supply diaphragm (mostly C4) C5, C6 Shoulder movement, raise arm (deltoid); flexion of elbow (biceps); C6 externally rotates the arm (supinates) C6, C7 Extends elbow and wrist (triceps and wrist extensors); pronates wrist C7, T1 Flexes wrist C7, T1 Supply small muscles of the hand T1 -T6 Intercostals and trunk above the waist T7-L1 Abdominal muscles L1, L2, L3, L4 Thigh flexion L2, L3, L4 Thigh adduction L4, L5, S1 Thigh abduction L5, S1, S2 Extension of leg at the hip (gluteus maximus) L2, L3, L4 Extension of leg at the knee (quadriceps femoris) L4, L5, S1, S2 Flexion of leg at the knee (hamstrings) L4, L5, S1 Dorsiflexion of foot (tibialis anterior) L4, L5, S1 Extension of toes L5, S1, S2 Plantar flexion of foot L5, S1, S2 Flexion of toes (Wikipedia, 2009) (Won’t be tested on this)
  142. 142. Spinal Cord Injury: Functionality of C1, C2, C3 Quadriplegic Mobility & Movement Limited head and neck movement depending on muscle strength. Complete paralysis of arms, body and legs. Sympathetic nervous system will be compromised, possibility of Autonomic Dysreflexia. Electric wheelchair may possibly be controlled by either a chin or "sip and puff" controller, this will vary depending on dexterity. The person will require total assistance when transferring from a bed to a wheelchair and from a wheelchair into a car. A hoist will have to be used, possibly by two assistants for safety. Complete assistance required during mealtimes. Respiratory System Inability to breathe using chest muscles or diaphragm, therefore the person will be dependant on a ventilator to breathe. A portable ventilator can be attached to the back of a wheelchair during transport. Oxygen and humidification may be required. Assistance required to clear secretions from trachea, and assistance in coughing will be required. Personal Care Complete personal assistance is required. The person will need assistance with washing, dressing, and assistance with bowel and bladder management. Domestic Care Complete domestic care is required, such as household cleaning, washing of clothes and kitchen duties, preparation of meals and general household duties. Communication A computer may be operated using iris recognition, mouth stick or voice recognition. Telephone can be used using voice recognition and headset. (Apparelyzed, 2009)
  143. 143. Spinal Cord Injury: Functionality of C4 Spinal Cord Injury Mobility & Movement Full head and neck movement depending on muscle strength. Limited shoulder movement. Complete paralysis of body and legs. No finger, wrist or elbow flexion or extension. Sympathetic nervous system will be compromised, possibility of Autonomic Dysreflexia. Electric wheelchair may be controlled by either a chin or "sip and puff" controller, this will vary depending on dexterity. The person will require total assistance when transferring from a bed to a wheelchair and from a wheelchair into a car. A hoist will have to be used, possibly by two assistants for safety. Complete assistance required during mealtimes. Respiratory System Able to breathe without a ventilator using diaphragm. Assistance required to clear secretions and assistance in coughing will be required. Personal Care Complete personal assistance is required. The person will need assistance with washing, dressing, and assistance with bowel and bladder management. Domestic Care Complete domestic care is required, such as household cleaning, washing of clothes and kitchen duties, preparation of meals and general household duties. Communication A computer may be operated using iris recognition, mouth stick or voice recognition. Telephone can be used using voice recognition and headset. (Apparelyzed, 2009)
  144. 144. Spinal Cord Injury: Functionality of C5 Spinal Cord Injury Mobility & Movement Full head and neck movement with good muscle strength. Good shoulder movement. Complete paralysis of body and legs. No finger or wrist movement. No elbow extension, good elbow flexion. Sympathetic nervous system will be compromised, possibility of Autonomic Dysreflexia. Electric wheelchair can be controlled with a hand control for uneven surfaces. A manual wheelchair may be used for short distances on flat surfaces. The person will require total assistance when transferring from a bed to a wheelchair and from a wheelchair into a car. A hoist will have to be used, possibly by one to two assistants for safety. Ability to feed self using feeding strap and fork or spoon during mealtimes. Food will need cutting. Respiratory System Able to breathe without a ventilator using diaphragm. Low stamina. Assistance required to clear secretions and assistance in coughing will be required. Personal Care Complete personal assistance is required. The person will need assistance with washing, dressing, and assistance with bowel and bladder management. Ability to shave and brush hair may be possible with palm straps. Domestic Care Complete domestic care is required, such as household cleaning, washing of clothes and kitchen duties, preparation of meals and general household duties. Communication A computer may be operated using a typing stick or voice recognition. Telephone can be used using voice recognition and headset. (Apparelyzed, 2009)
  145. 145. Spinal Cord Injury: Functionality of C6 Spinal Cord Injury Mobility & Movement Full head and neck movement with good muscle strength. Good shoulder movement. Complete paralysis of body and legs. No finger movement, no elbow extension, no wrist flexion. Good wrist extension, good elbow flexion. A passive key grip may be present by flexing the wrist backwards, but will be weak. Sympathetic nervous system will be compromised, possibility of Autonomic Dysreflexia. Electric wheelchair can be controlled with a hand control for uneven outdoor surfaces. A manual wheelchair may be used for short distances on flat surfaces. The person will require total assistance when transferring from floor to chair. Assistance will vary for transfer from bed to wheelchair, and wheelchair to car. A sliding board may be used in assisting with the transfer Ability to feed self using feeding strap and fork or spoon during mealtimes. Food will need cutting. Able to make hot drinks with adapted kettle using a "kettle tipper". Respiratory System Able to breathe without a ventilator using diaphragm. Low stamina. Assistance required to clear secretions and assistance in coughing may be required. Additional coughing techniques can be applied to assist in coughing by leaning forward whilst exhaling. Personal Care Personal assistance is required. The person will need assistance with washing, dressing, and assistance with bowel and bladder management. Ability to empty own legbag will depend on dexterity and strength. Ability to partially dress upper body, however, assistance may be required to dress lower body. Ability to shave, brush hair and brush teeth is possible with palm straps. Domestic Care Complete domestic care is required, such as household cleaning, washing of clothes and kitchen duties. Ability with adapted equipment to prepare simple meals and simple general household duties. Communication A computer may be operated using a typing stick or voice recognition. Telephone can be used using voice recognition and headset. (Apparelyzed, 2009)
  146. 146. Spinal Cord Injury: Functionality of C7 - C8 Spinal Cord Injury Mobility & Movement Full head and neck movement with good muscle strength. Good shoulder movement. Complete paralysis of body and legs. Partial finger movement,full elbow extension and flexion, full wrist extension and flexion. A C7 injured person will have movement in the thumb. Sympathetic nervous system will be compromised, possibility of Autonomic Dysreflexia. May use an electric wheelchair for long independent travel or uneven outdoor surfaces. A manual wheelchair may be used for short distances on flat surfaces. Ability to transfer independently from bed to chair, and chair to car. Car transfers may need assistance depending on upper body strength. Ability to drive a car adapted with hand controls. Assistance may be required to load wheelchair into car independently. Ability to feed self independently during mealtimes. Food may need cutting. Able to make hot drinks , may require an adapted kettle using a "kettle tipper". Respiratory System Able to breathe without a ventilator using diaphragm. Low stamina. Assistance required to clear secretions and assistance in coughing may be required. Additional coughing techniques can be applied to assist in coughing by leaning forward whilst exhaling. Personal Care Ability to manage bladder and bowel independently will vary depending on strength and dexterity. Independent in upper body showering and dressing, lower body dressing and showering may need assistance. Independent in grooming, usually without palm straps. Domestic Care Partial domestic assistance is required, such as heavy household cleaning, home maintenance, and complex preparation of meals. Ability to prepare simple meals and simple general household duties independently. Communication A computer may be operated using a typing stick or voice recognition. Telephone can be used using voice recognition and headset.
  147. 147. Spinal Cord Injury: Functionality of T1 - T4 Paraplegic Mobility & Movement Full head and neck movement with normal muscle strength. Normal shoulder movement. Full use of arms, wrists and fingers. Complete paralysis of lower body and legs. Upper body strength will vary depending on level of injury, but the lower the level, the stronger the upper body strength and balance. A T4 injured person will have good strength in the chest muscles, however this will get progressively weaker the higher up the injury. Sympathetic nervous system may be compromised, possibility of Autonomic Dysreflexia. May use an electric wheelchair for long distance independent travel or uneven outdoor surfaces. A manual wheelchair may be used for everyday living, with the ability to go over uneven ground for short distances. Ability to transfer independently from bed to chair, and chair to car. Car transfers may need assistance depending on upper body strength. Ability to drive a car adapted with hand controls. Assistance may be required to load wheelchair into car. Ability to feed self independently during mealtimes. Respiratory System Ability to breathe normal, although respiration capacity and endurance may be compromised. Personal Care Should be independent in personal care as long as no other factors are involved, ie, additional injuries, severe spasticity etc. Domestic Care Partial domestic assistance is required, such as heavy household cleaning and home maintenance. Ability to prepare complex meals and general household duties independently. Communication Normal communication skills apply.
  148. 148. Spinal Cord Injury: Functionality of T5 - T9 Spinal Cord Injury Mobility & Movement Full head and neck movement with normal muscle strength. Normal shoulder movement. Full use of arms, wrists and fingers. Complete paralysis of lower body and legs. Upper body strength will vary depending on level of injury, but the lower the level, the stronger the upper body strength and balance. A manual wheelchair may be used for everyday living, with the ability to go over uneven ground. Ability to transfer independently from bed to chair, and chair to car. Car transfers may need assistance depending on upper body strength. Ability to drive a car adapted with hand controls. Assistance may be required to load wheelchair into car. Respiratory System Ability to breathe normal, although respiration capacity and endurance may be compromised. Personal Care Should be independent in personal care as long as no other factors are involved, ie, additional injuries, severe spasticity etc. Domestic Care Partial domestic assistance is required, such as heavy household cleaning and home maintenance. Ability to prepare complex meals and general household duties independently. Communication Normal communication skills apply. (Apparelyzed, 2009)
  149. 149. Spinal Cord Injury: Functionality of T10 - L1 Spinal Cord Injury Mobility & Movement Full head and neck movement with normal muscle strength. Normal shoulder movement. Full use of arms, wrists and fingers. Partial paralysis of lower body and legs. Upper body strength and balance will vary depending on level of injury, but the lower the level, the stronger the upper body strength and balance. A manual wheelchair may be used for everyday living, with the ability to go over uneven ground. Ability to transfer independently from bed to chair, and chair to car. It may be possible to transfer from floor to chair depending on upper body strength. It may also be possible to transfer from sitting position to standing frame independently. Ability to drive a car adapted with hand controls. Ability to load wheelchair into car independently. Respiratory System Normal respiratory system. Personal Care Should be independent in personal care as long as no other factors are involved, ie, additional injuries, severe spasticity etc. Domestic Care Partial domestic assistance is required, such as heavy household cleaning and home maintenance. Ability to prepare complex meals and general household duties independently. Communication Normal communication skills apply. (Apparelyzed, 2009)
  150. 150. Spinal Cord Injury: Functionality of L2 - S5 Spinal Cord Injury Mobility & Movement Full head and neck movement with normal muscle strength. Normal shoulder movement. Full use of arms, wrists and fingers. Full upper body control and balance. Some hip, knee and foot movement depending on the level of injury. The lower the injury, the more control over movement. A manual wheelchair may be used for everyday living, with the ability to go over uneven ground. Ability to transfer independently from bed to chair, and chair to car. It may be possible to transfer from floor to chair depending on upper body strength. Depending on the level of injury, walking may be possible with assistance or aids. Walking will be slow and difficult though. Ability to drive a car adapted with hand controls. Ability to load wheelchair into car independently. Respiratory System Normal respiratory system. Personal Care Should be independent in personal care as long as no other factors are involved, ie, additional injuries, severe spasticity etc. Domestic Care Partial domestic assistance is required, such as heavy household cleaning, home maintenance. Ability to prepare complex meals and general household duties independently. Communication Normal communication skills apply. (Apparelyzed, 2009)

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