Management of Patients with Neurologic Disorders

Headache
Cephalgia
A symptom rather than a disease entity; it may indicate organic disease (neurologic or other disease), a stressresponse, vasodilation (migraine), skeletal muscle tension (tension headache), or a combination of factors. Diagnostic testing is often not helpful in the investigation of headache as there are often few objective findings.

and tingling of the lips, face, or hands; mild confusion; slight weakness of an extremity; drowsiness; and dizziness. 3. Headache Phasethrobbing; can be severe and incapacitating duration varies, ranging from 4 to 72 hours 4. Recovery Phase
Medical Management Abortive Approach best employed in patients who suffer less frequent attacks, is aimed at relieving or limiting a headache at the onset or while it is in progress. Preventive Approach - used in patients who experience more frequent attacks at regular or predictable intervals and may have medical conditions that preclude the use of abortive therapies Triptans - serotonin receptor agonists, are the most specific antimigraine agents available. Sumatriptan (Imitrex) naratriptan (Amerge) rizatriptan (Maxalt) Zolmitriptan (Zomig) almotriptan Nursing Management Rest , plenty of water Primary Brain Tumors A localized intracranial lesion that occupies space within the skull. Brain tumors rarely metastasize outside the CNS, but metastatic lesions to the brain. Occur commonly from the lung, breast, lower gastrointestinal tract, pancreas, kidney, and skin (melanomas). The cause is unknown.

Migraine
symptom complex characterized by periodic and recurrent attacks of severe headache. cause of migraine has not been clearly demonstrated, but it is primarily a vascular disturbance that occurs more commonly in women and has a strong familial tendency. highest in adults 20 to 35 years of age. more chronic than severe and are probably the most common type of headache. a steady, constant feeling of pressure that usually begins in the forehead, temple, or back of the neck more chronic than severe and are probably the most common type of headache. unilateral and come in clusters of one to eight daily, with excruciating pain localized to the eye and orbit and radiating to the facial and temporal regions. Penetrating and steady pain Clinical manifestations associated with inflammation

Tension headaches

Cluster headaches

Classification of Adult Brain Tumors

I. Intracerebral Tumors A. Gliomasinfiltrate any portion of the brain; most common type of brain tumor 1. Astrocytomas (grades I and II) 2. Glioblastoma multiforme (astrocytoma grades III and IV) 3. Oligodendrocytoma (low and high grades) 4. Ependymoma (grades I to IV) 5. Medulloblastoma II. Tumors Arising From Supporting Structures A. Meningiomas B. Neuromas (acoustic neuroma, schwannoma) C. Pituitary adenomas III. Developmental Tumors A. Angiomas B. Dermoid, epidermoid, teroma, craniopharyngioma

Cranial arteritis

Clinical Manifestations: Migraine 1. Prodrome (60%)symptoms that occur hours to days before a migraine headache.depression, irritability, feeling cold, food cravings, anorexia, change in activity level, increased urination, diarrhea, or constipation. 2. Aura Phase-aura usually lasts less than an hour and may provide enough time for the patient to take the prescribed medication.Visual disturbances; numbness

IV. Metastatic Lesions Clinical Manifestations

Increasing ICP Headache Vomiting Visual Disturbances Diagnostic Findings CT scan MRI PET EEG Medical Management Chemotherapy External-beam radiation therapy Brachytherapy the surgical implantation of radiation sources to deliver high doses at a short distance Intravenous (IV) autologous bone marrow transplantation Surgical Management The objective of surgical management is to remove or destroy the entire tumor without increasing the neurologic deficit (paralysis, blindness) or to relieve symptoms by partial removal (decompression). Transsphenoidal microsurgical removal Craniotomy

Anxiety related to fear of dying, uncertainty, change in appearance, altered lifestyle Interrupted family processes related to anticipatory grief and the burdens imposed by the care of the person with a terminal illness

Nursing Interventions
IMPROVING NUTRITION Meals are planned for the times the patient is rested and in less distress from pain or the effects of treatment. The family may be asked to keep a daily weight chart and to record the quantity of food eaten to determine the daily calorie count. Tube feeding, parenteral nutrition

Intracranial Infections
Meningitis
an inflammation of the meninges, the protective membranes that surround the brain and spinal cord a. aseptic meningitis - bacteria are not the cause of the inflammation; the cause is viral or secondary to lymphoma, leukemia, or brain abscess b. Septic meningitis - caused by bacteria, most commonly Neisseria meningitidis, although Haemophilus influenzae and Streptococcus pneumoniae are also causative agents. Headache Fever Nuchal rigidity (stiff neck) is an early sign. Any attempts at flexion of the head are difficult because of spasms in the muscles of the neck. Forceful flexion causes severe pain. Positive Kernig s sign: When the patient is

NURSING PROCESS:
THE PATIENT WITH CEREBRAL METASTASES OR INCURABLE BRAIN TUMOR Assessment Assessment addresses symptoms that cause distress to the patient, including pain, respiratory problems, bowel and bladder disorders, sleep disturbances, and impairment of skin integrity, fluid balance, and temperature regulation. Nutritional status is assessed

Clinical Manifestations

Diagnosis
Self-care deficit (feeding, bathing, and toileting) related to loss or impairment of motor and sensory function and decreased cognitive abilities Imbalanced nutrition, less than body requirements, related to cachexia due to treatment and tumor effects, decreased nutritional intake, and malabsorption

lying with the thigh flexed on the abdomen, the leg cannot be completely extended.
Positive Brudzinski s sign: When the patient s neck is flexed,

o flexion of the knees and hips is produced; when passive flexion of the lower extremity of one side is made, a similar movement is seen in the opposite extremity

Photophobia: extreme sensitivity to light; this finding is common, although the cause is unclear. Skin lesions develop, ranging from a petechial rash with purpuric lesions to large areas of ecchymosis. Disorientation and memory impairment are common early in the course of the illness Seizures occur secondary to focal areas of cortical irritability. Intracranial pressure increases secondary to accumulation of purulent exudate.

Protecting the patient from injury secondary to seizure activity or altered level of consciousness Preventing complications associated with immobility, suchas pressure ulcers and pneumonia Instituting droplet precautions until 24 hours after the initiationof antibiotic therapy (oral and nasal discharge is considered (infectious)

Brain Abscess
A brain abscess is a collection of infectious material within the tissue of the brain. Etiology direct invasion of the brain from intracranial trauma or surgery spread of infection from nearby sites, such as the sinuses, ears, and teeth (paranasal sinus infections, otitis media, dental sepsis by spread of infection from other organs (lung abscess, infective endocarditis) CT Scan

Diagnostic Findings
Bacterial culture and Gram staining of CSF and blood are key diagnostic

Tests The presence of polysaccharide antigen in CSF further supports the diagnosis of bacterial meningitis

Prophylaxis
rifampin (Rifadin) ciprofloxacin hydrochloride (Cipro) ceftriaxone sodium (Rocephin) Vaccination ! Therapy should be started as soon as possible after contact; a delay in the initiation of therapy will limit the effectiveness of the prophylaxis Medical Management Penicillin antibiotics (eg, ampicillin, piperacillin) Cephalosporins (eg, ceftriaxone sodium, cefotaxime sodium) Vancomycin hydrochloride alone or in combination with rifampin may be used if resistant strains of bacteria are identified Dexamethasone - given 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days Phenytoin (Dilantin)

Herpes Simplex Encephalitis

HSV-1 infection of the buccal mucosa occurs, followed by retrograde spread along the trigeminal nerve to the brain. HSV-1 encephalitis causes inflammation and necrosis in the temporal lobe, frontal lobe, and limbic system. MRI Neuroimaging study of choice Acyclovir (Zovirax) medication of choice Assessment of neurologic function Comfort measures to reduce headache Opioid analgesic medications may mask neurologic symptoms; therefore, they are used cautiously.

Diagnostic Exam

NI

Nursing Management
Neurologic status and vital signs are continually assessed.

Degenerative Neurologic Disorders

Multiple Sclerosis
immune-mediated progressive demyelinating disease of the CNS Demyelination destruction of myelin, the fatty and protein material that surrounds certain nerve fibers in the brain and spinal cord; it results in impaired transmission of nerve impulses (fig. 1946) 20 to 40 y.o., more women than men

o Pulse oximetry and arterial blood gas values

Endotracheal tube (or tracheotomy) and mechanical ventilation Monitoring body weight, serum electrolytes, and urine volume,specific gravity, and osmolality, especially if the syndrome of inappropriate antidiuretic hormone (SIADH)secretion is suspected

Clinical Manifestations
Fatigue Depression Weakness Numbness difficulty in coordination, loss of balance Pain blurring of vision, diplopia, patchy blindness (scotoma), and total blindness Spasticity (muscle hypertonicity) of the extremities and loss of the abdominal reflexes inability to store urine (hyperreflexic, uninhibited) Inability to empty the bladder (hyporeflexic, hypotonic) a mixture of both types

Use of assistive device A stretch hold relax routine is helpful for relaxing and treating muscle spasticity. Swimming and stationary bicycling and progressive weight-bearing can relieve spasticity in the legs PREVENTING INJURY

ENHANCING BLADDER AND BOWEL CONTROL

The patient is instructed to drink a measured amount of fluid every 2 hours and then attempt to void 30 minutes after drinking. Using a timer or wristwatch with an alarm may be helpful for the patient who does not have enough sensation to signal the need to empty the bladder. Intermittent self-catheterization Adequate fluids dietary fiber bowel-training program

Medical Management MRI primary diagnostic tool for visualizing plaques, documenting disease activity, and evaluating the effect of treatment. No cure exists.

Nursing Interventions
MANAGING SPEECH AND SWALLOWING DIFFICULTIES A speech therapist evaluates speech and swallowing IMPROVING SENSORY AND COGNITIVE FUNCTION Diplopia eye patch or a covered eyeglass ! no two patients with MS have identical symptoms or courses of illness IMPROVING SELF-CARE ABILITIES assistive eating devices raised toilet seat bathing aids telephone modifications longhandled comb modified clothing PROMOTING SEXUAL FUNCTIONING

NURSING PROCESS:
THE PATIENT WITH MULTIPLE SCLEROSIS

Assessment
The patient is assessed for weakness, spasticity, visual impairment, incontinence, and disorders of swallowing andspeech. How has MS affected the patient s lifestyle? How well is the patientcoping? What would the patient like to do better? Impaired physical mobility related to weakness, muscle paresis, spasticity Risk for injury related to sensory and visual impairment Impaired urinary and bowel elimination (urgency, frequency, incontinence, constipation) related to nervous systemdysfunction Impaired speech and swallowing related to cranial nerve involvement Disturbed thought processes (loss of memory, dementia, euphoria) related to cerebral dysfunction

Diagnosis

MYASTHENIA GRAVIS
autoimmune disorder affecting the myoneural junction, is characterized by varying degrees of weakness of the voluntary muscles. (fig 1953) Diplopia (double vision) ptosis (drooping of the eyelids) weakness of the muscles of the face and throat (bulbar symptoms)generalized weakness dysphonia (voice impairment) and increases the patient s risk for choking and aspiration

Clinical Manifestations

Nursing Interventions
PROMOTING PHYSICAL MOBILITY Relaxation and coordination exercises promote muscle efficiency. Progressive resistive exercises are used to strengthen weak muscles

Medical Management Anticholinesterase agents [pyridostigmine bromide (Mestinon) and neostigmine bromide (Prostigmin)] provide symptomatic relief by increasing the relative concentration of available acetylcholine at the neuromuscular junction. Maintenance of stable blood levels of anticholinergic medication is imperative to stabilize muscle strength. Prednisone

PLASMAPHERESIS
a technique used to treat exacerbations

a) The patients plasma and plasma components are removed through a centrally placed large-bore double-lumen catheter. b) The blood cells and antibody-containing plasma are separated c) The cells and a plasma substitute are reinfused.
Plasma exchange produces a temporary reduction in the titer of circulating antibodies. Plasma exchange improves the symptoms in 75% of patients, although improvement lasts only a few weeks unless plasmapheresis is continued or other forms of treatment such as immunosuppression with corticosteroids are initiated IV immune globulin (IVIG) SURGICAL MANAGEMENT Thymectomy (surgical removal of the thymus gland) produce antigen-specific immunosuppression and result in clinical improvement. The entire gland must be removed for optimal clinical outcomes; therefore, surgeons prefer the transsternal surgical approach 92% of post-thymectomy patients had symptomatic improvement, with 50% of them no longer requiring pharmacologic therapy

Differentiation can be achieved with the edrophonium chloride (Tensilon) test. The patient with myasthenic crisis improves immediately following administration of edrophonium patient with cholinergic crisis may experience no improvement or deteriorate. Myasthenic crisis -neostigmine methylsulfate (PMS-Neostigmine, Prostigmin) Cholinergic crisis - Atropine sulfate Neuromuscular respiratory failure critical complication negative inspiratory force and vital capacity

GUILLAIN-BARR SYNDROME
autoimmune attack of the peripheral nerve myelin. acute, rapid segmental demyelination of peripheral nerves and some cranial nerves, producing ascending weakness with dyskinesia (inability to execute voluntary movements), hyporeflexia, and paresthesias (numbness) predisposing event: a respiratory or gastrointestinal infection Antecedent event (2weeks): vaccination, pregnancy, and surgery Weakness usually begins in the legs and progresses upward for about 1 month. Maximum weakness varies but usually includes neuromuscular respiratory failure and bulbar weakness. Any residual symptoms are permanent and reflect axonal damage from demyelination.

Myelin is a complex substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites Clinical Manifestations muscle weakness and diminished reflexes of the lower extremities Quadriplegia neuromuscular respiratory failure Ascending weakness Medical Management assessment of changes in motor weakness and respiratory function Respiratory therapy or mechanical ventilation use of anticoagulant agents and thigh-high elastic compression stockings or sequential compression boots IVIG and plasmapheresis

Myasthenic Crisis Vs. Cholinergic Crisis

A myasthenic crisis exacerbation of the disease process characterized by severe generalized muscle weakness and respiratory and bulbar weakness that may result in respiratory failure. Precipitator is infection; others include medication change, surgery, pregnancy, and high environmental temperature Cholinergic crisis anticholinergic medication may mimic the symptoms of exacerbation

NURSING PROCESS:
THE PATIENT WITH GUILLAIN-BARR SYNDROME Ineffective breathing pattern and impaired gas exchange related to rapidly progressive weakness and impending respiratory failure Impaired physical mobility related to paralysis Imbalanced nutrition, less than body requirements, related to inability to swallow Impaired verbal communication related to cranial nerve dysfunction Fear and anxiety related to loss of control and paralysis

Patients take longer to complete most activities and have difficulty initiating movement, such as rising from a sitting position or turning in bed. freezing phenomenon - extreme form of bradykinesia Micrographia Dysphonia (soft, slurred, low-pitched, and less audible speech) The face becomes increasingly masklike and expressionless and the frequency of blinking decreases. The patient commonly develops postural and gait problems. Medical Management Laboratory tests and imaging studies are not helpful in the diagnosis of Parkinson s disease

Nursing Interventions
MAINTAINING RESPIRATORY FUNCTION Spirometry and chest physiotherapy (vital capacity and negative inspiratory force). Suctioning Monitor the blood pressure and heart rate frequently ENHANCING PHYSICAL MOBILITY PROVIDING ADEQUATE NUTRITION IV fluids and parenteral nutrition (paralytic ileus) a gastrostomy tube

Antiparkisonian Medications
Levodopa (Dopar, Larodopa) most effective agent and the mainstay of treatment converted to dopamine in the basal ganglia, producing symptom relief damages the substantia nigra and eventually speeds disease progression Dyskinesia - facial grimacing, rhythmic jerkin movements of the hands, head bobbing, chewing and smacking movements, and involuntary movements of the trunk and extremities Trihexyphenidyl, cycrimine, procyclidine, biperiden, and benztropine mesylate effective in controlling tremor and rigidity side effects include blurred vision, flushing, rash, constipation, urinary retention, and acute confusional states Amantadine hydrochloride (Symmetrel) is an antiviral agent used in early Parkinson s treatment to reduce rigidity, tremor, and bradykinesia Bromocriptine mesylate and pergolide Tricyclic antidepressants may be prescribed to alleviate the depression that is so common in Parkinson s disease.

Parkinson s Disease
slowly progressing neurologic movement disorder that eventually leads to disability. degenerative or idiopathic form a secondary form with a known or suspected cause Etiology: Unknown Genetics, atherosclerosis, excessive accumulation of oxygen free radicals, viral infections, head trauma, chronic antipsychotic medication use, and some environmental exposures

Anticholinergic Therapy

Antiviral Therapy

Clinical Manifestations
TREMOR resting tremor 70% Resting tremor characteristically disappears with purposeful movement but is evident when the extremities are motionless. Pill rolling increases when the patient is walking, concentrating, or feeling anxious. RIGIDITY Resistance to passive limb movement Stiffness of the neck, trunk, and shoulders is common. BRADYKINESIA

Dopamine Agonists Antidepressants

NURSING PROCESS:
THE PATIENT WITH PARKINSON S DISEASE Assessment Observe for degree of disability and the functional changes that occur throughout the day, such as responses to medication

Do you have leg or arm stiffness? Have you experienced any irregular jerking of your arms or legs? Have you ever been frozen or rooted to the spot and unable to move? Does your mouth water excessively? Have you (or others) noticed yourself grimacing or making faces or chewing movements? What specific activities do you have difficulty doing? NURSING DIAGNOSES Impaired physical mobility related to muscle rigidity and motor weakness Self-care deficits (feeding, dressing, hygiene, and toileting) related to tremor and motor disturbance Constipation related to medication and reduced activity Imbalanced nutrition, less than body requirements, related to tremor, slowness in eating, difficulty in chewing and swallowing Impaired verbal communication related to decreased speech volume, slowness of speech, inability to move facial muscles Ineffective coping related to depression and dysfunction due to disease progression

Clinical Manifestations
Forgetfulness Subtle memory loss Depression lose their ability to recognize familiar faces, places, and objects and may get lost in a familiar environment may repeat the same stories because they forget that they have already told them. Trying to reason with the person and using reality orientation only increase the patient s anxiety without increasing functionunable to recognize the consequences of his or her actions and will therefore exhibit impulsive behavior Personality changes - depressed, suspicious, paranoid, hostile, and even combative. Speaking skills deteriorate to nonsense syllables, agitation and physical activity increase, and the patient may wander at night assistance is needed for most ADLs Death occurs as a result of complications such as pneumonia, malnutrition, or dehydration.

Diagnostic Findings
CT and MRI scans of the brain are useful for excluding hematoma, brain tumor, stroke, normal-pressure hydrocephalus, and atrophy but are not reliable in making a definitive diagnosis of Alzheimer s disease. Medical Management tacrine hydrochloride (Cognex) - enhances acetylcholine uptake in the brain, thus maintaining memory skills for a period of time. donepezil (Aricept) rivastigmine (Exelon) Nsg. M Research has demonstrated that when the nurse can provide such support, older adults are able to maintain higher levels of perceived and actual health SUPPORTING COGNITIVE FUNCTION Provides calm, predictable environment that helps the person interpret his or her surroundings and activities. Environmental stimuli are limited, and a regular routine is followed. Communicate in quiet, pleasant manner of speaking, clear and simple explanations, and use of memory aids and cues help to minimize confusion and disorientation and give the patient a sense of security. Prominently displayed clocks and calendars

Nursing Interventions IMPROVING MOBILITY

Teach to concentrate on walking erect, to watch the horizon, and to use a wide-based gait (ie, walking with the feet separated). practice walking to marching music or to the sound of a ticking metronome because this provides sensory reinforcement Frequent rest periods aid in preventing frustration and fatigue. ENHANCING SELF-CARE ACTIVITIES IMPROVING BOWEL ELIMINATION Problems with constipation ENHANCING SWALLOWING A semisolid diet with thick liquids is easier to swallow than solids; thin liquids should be avoided. It is helpful for patients to think through the swallowing sequence

Alzheimer s disease
progressive, irreversible, degenerative neurologic disease that begins insidiously and is characterized by gradual losses of cognitive function and disturbances in behavior and affect.

 Colorcoding the doorway PROMOTING PHYSICAL SAFETY All obvious hazards are removed. Nightlights Monitor patient s intake of medications and food Smoking is allowed only with supervision. Wandering behavior - gently persuading or distracting the patient Avoid restraints Wear an identification bracelet or neck chain REDUCING ANXIETY AND AGITATION Patient will, at times, be aware of his or her rapidly diminishing abilities. The environment should be kept uncluttered, familiar, and noise free. Excitement and confusion can be upsetting and may precipitate a combative, agitated state known as a catastrophic reaction (overreaction to excessive stimulation). Remain calm and unhurried. Measures such as listening to music, stroking, rocking, or distraction PROMOTING INDEPENDENCE IN SELF-CARE ACTIVITIES simplify daily activities by organizing them into short, achievable steps so that the patient experiences a sense of accomplishment. maintain personal dignity and autonomy PROVIDING FOR SOCIALIZATION AND INTIMACY NEEDS visits, letters, and phone calls are encouraged. Visits should be brief and nonstressful; limiting visitors to one or two at a time helps to reduce overstimulation. the person is encouraged to enjoy simple activities as walking, exercising, and socializing Pet Alzheimer s disease does not eliminate the need for intimacy. The patient and his or her spouse may or may not continue to enjoy sexual activity. Simple expressions of love, such as touching and holding, are often meaningful. PROMOTING ADEQUATE NUTRITION Mealtime should be kept simple and calm, without confrontations To avoid the patient s playing with the food, one dish is offered at a time. Food is cut into small pieces to prevent choking. Liquids may be easier to swallow if they are converted to gelatin.

Temperature of the foods should be checked to prevent burns. it may be necessary to feed the patient. Barriers: Forgetfulness Disinterest Dental problems Incoordination Overstimulation Choking PROMOTING BALANCED ACTIVITY AND REST the patient should be given sufficient opportunity to participate in exercise activities Long periods of daytime sleeping are discouraged.

Creutzfeldt-Jakob Disease (CJD) and NewVariant Creutzfeldt-Jakob (nvCJD)

belong to a group of degenerative, infectious neurologic disorders called transmissible spongiform encephalopathies (TSE). Both are rare and have incubation periods ranging from months to decades. Symptoms: progressive No definitive treatment Outcome: fatal CJD occurs primarily in adults ages 50 to 70 nvCJD occurs in younger patients and has a prolonged duration of illness compared to CJD Dementia Mutism visual changes cerebellar, pyramidal extrapyramidal signs myoclonic jerks Anxiety, depression, and behavioral changes are the initial symptoms of nvCJD. gait changes and ataxia Memory and cognitive impairments occur late sharp waves and spikes on the EEG were the only features available to support the diagnosis of CJD Detection of a polyclonal antibody (protein 14-3-3) in CSF The care of the patient is supportive and palliative. The duration of disease is 4 to 5 months in CJD and 16 months in nvCJD, with death occurring as a result of respiratory failure or sepsis

Clinical Manifestations

Diagnostic Findings

Medical Management

Nursing Management
The nursing care of patients is primarily supportive and palliative. Psychological and emotional support of patients and families throughout the course of the illness is needed Blood and body fluid exposure and decontamination of equipment. Conventional methods of sterilization do not destroy the prion

MUSCULAR DYSTROPHIES group of chronic muscle disorders characterized by progressive weakening and wasting of the skeletal or voluntary muscles. Inherited Degeneration and loss of muscle fibers, variation in muscle fiber size, phagocytosis and regeneration, and replacement of muscle tissue by connective tissue. Med. M. Supportive care and preventing complications individualized therapeutic exercise program is prescribed to prevent muscle tightness, contractures, and disuse atrophy Night splints and stretching exercises are used to delay contractures of the joints, especially the ankles, knees, and hips. Braces may compensate for muscle weakness. Weakness of trunk muscles and spinal collapse occur - fitted with an orthotic jacket to improve sitting stability and reduce trunk deformity spinal fusion Weakness of the facial muscles gastric dilation, rectal prolapse, and fecal impaction cardiomyopathy appears to be a common complication in all forms of muscular dystrophy Nsg. M. actively involved family and patient decisionmaking, including end-of-life decisions.