Transcript lecture 6: Chapter 22 The Neurologic System

CHAPTER
22
Lecture Note PowerPoint Presentation
The Neurologic System
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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LEARNING OUTCOME 1
Describe the components of the neurological
system.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Neurological System
• Central nervous system (CNS)
– Brain
– Spinal cord
• Peripheral nervous system
– Cranial nerves
– Spinal nerves
– Somatic nervous system
– Autonomic nervous system
– Reflex arc
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Figure 22-1
An illustration of the right hemisphere of the brain. In dark brown, the cerebellum. In
beige, from bottom to top, the medulla oblongata and the pons. Just above it and slightly
lighter, the corpus callosum.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OUTCOME 2
Describe progressive dementias.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Dementia
• Progressive disorder
• Characterized by a loss of cognition and at
least one of the following
– Ability to speak coherently and understand
language
– Ability to recognize or identify objects
– Ability to execute motor activities
– Ability to think abstractly, make sound
judgment, and plan and carry out complex
tasks
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Dementia
• Aging is the greatest risk factor
• Clinical diagnosis
– Loss of intellectual ability with impairment that
interferes with social or occupational
functioning
– Delirium has been ruled out
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Dementia
• Risk factors
– Delirium
– Mild cognitive impairment
– Vascular dementia
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Dementia
• Types
– Alzheimer’s disease (AD)
 Abnormalities in the brain structure disrupts the
health of neurons
 Manifestations include memory failure, personality
changes, and difficulty with ADLs
 Causes
•
•
•
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•
•
Genetics
Age
Gender
Race
Head injury
Environmental exposures
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Dementia
• Types
– Vascular dementia
 Abrupt onset of dementia
 Focal neurological findings
 Low-density areas indicate vascular changes in
white matter
 Multiple strokes in CT or MRI present
 Unchanged personality
 Emotional problem
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Dementia
• Types
– Lewy body dementia
 Clinical features persist over long period of time
resulting in severe dementia
 Lewy bodies and Lewy neuritis found in brain
structures
– Frontotemporal lobe dementia
 Diagnosed based upon personality changes
 Presence of frontal brain area atrophy in CT or
MRI
Lewy bodies : are abnormal aggregates of protein that develop inside nerve cells in
Parkinson's disease (PD) and Alzheimer's disease (AD) and some other disorders.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OUTCOME 3
Discuss the stages of Alzheimer’s disease
and implications for nursing care.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
AD
• Progressive disorder
• Results in the death of nerve cells
– Memory failure
– Personality changes
– Increasing inability to manage activities of
daily living
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Figure 22-4
Plaques and tangles: The hallmark of AD.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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AD
• Diagnosis
– History
– Physical examination
– Neuropsychological testing
– Definitive diagnosis: autopsy after death
Autopsy : is a medical procedure that consists of a thorough
examination of a body to determine the cause and manner of death
and to evaluate any disease or injury that may be present
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
AD
• Risk factors
– Advancing age
– Family history
– Head trauma
– Diabetes mellitus
– Clinical depression
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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AD
• Stages
– Stage 1, Mild
– Stage 2, Moderate
– Stage 3, Severe
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nurse’s Role
•
•
•
•
•
Promote independence and autonomy
Prevent complications
Provide comfort
Promote quality of life
Education
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Planning Care
• No cure available
• Goals of treatment
– Slow progression
– Manage manifestations
• Caregiver experience needed
– Long-term care
– End-of-life care
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Planning Care
• Challenging behaviors and psychiatric
symptoms develop in the AD patient
• Settings used to care for AD patients
– Individual’s home or family member’s home
– Hospitals
– Long-term-care facilities (nursing homes)
– Congregate living facilities
– Hospice settings
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pharmacological Interventions
• Cholinesterase inhibitors
– Slow progression of symptoms
– Titrate dosages slowly
 Donepezil (Aricept)
 Rivastigmine (Exelon)
 Galantamine (Reminyl)
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Pharmacological Interventions
• Memantine (Namenda)
– N-methyl-d-aspartate (NMDA) antagonist
• Alternative and complementary therapies
– Vitamin E: limited support, more study needed
– Nonsteroidal anti-inflammatory drugs/statins:
patients taking these have reduced
development of AD
– Statins:are a class of drug used to lower cholesterol levels by inhibiting
the enzyme HMG-CoA reductase.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Environmental Safety
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•
•
•
•
Modify home to promote safety
Door locks
Secure rugs
Decrease water heater temperature
Handrails in bathroom
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Functional Impairments
• Utilize therapeutic nonverbal behaviors
• Avoid fatigue, nonroutine activities, and
alcohol
• Avoid a high-stimulus environment
• Prevent disability
• Treat other conditions that lead to physical
decline
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Functional Impairments
• Identify and respond rapidly to acute
changes in function
• Adapt care to accommodate neuromotor
changes secondary to progression of
dementia
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Mood Disorders
• Be alert for changes
– Appetite
– Disinterest
– Anhedonia
– Sleep abnormality
– Fatigue
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Delusions and Hallucinations
• Cause
– Delirium
– Interaction of dementia and personality
– Separate mental disorder coexisting with
dementia
– Disinhibition of cortical functions
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Dependence in ADLs
• Promote, preserve functional
independence
• Preventive plans of care
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Inability to Initiate Meaningful
Activities
• Results in apathy or agitation for dementia
sufferer
• Promote social involvements
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Anxiety
• May be a primary disorder or a symptom
of depression
• May result from delusions, hallucinations,
or functional impairment
• Plan interventions to reduce stress,
enhance feelings of trust and safety
• Promote stability
• Provide diversion activities
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Spatial Disorientation
• Results in incorrect interpretation of
objects or directions
• Results in fear, anxiety, suspicions,
illusions, delusions, and safety concerns
• Promote familiarity with environment
• Use landmarks to provide “pop-up” cues
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Elopement
• means to run away, and to not come back
to the point of origination
• A valid concern in individuals with
cognitive impairments
• Risk factors
• Alzheimer’s Association Safe Return
Program
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Resistance to Care
• Common in middle to late stages of
dementia
• Major reason for institutionalization and
use of psychotropic medications and
restraints
• Management strategies
– Restore calm
– Time-out
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Food Refusal
• Occurs in each of the progressive stages
of AD
• Causes
• Management interventions
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Insomnia
• Insomnia noted months prior to AD
diagnosis
• Establish routines to promote therapeutic
sleep patterns
– Establish sleep hygiene
– Eliminate stimuli before bedtime
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Apathy and Agitation
• Associated with increasing cognitive
decline
• Escalation can result in violence and
combative behaviors
• Promote interest in the environment
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pharmacological Interventions
• Used to promote comfort
• Begin with lower dosages and gradually
increase
• Monitor side effects closely
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Late Stage Issues
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•
•
•
•
Institutionalization
Do not resuscitate decisions
Transfer to acute care facilities
Feeding tubes
Infections
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OUTCOME 4
Describe a contextual model to direct
behavioral and pharmacological
interventions for behavioral symptoms of
Alzheimer’s disease.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
A Contextual Model for Symptom
Management for AD
• Core = dementia + personality
– Delusions – spatial disorientation = elopement
+ agitation
– Hallucinations – functional impairment
– Mood disorders – depression – anxiety +
inability to initiate meaningful activities –
apathy + repetitive vocalization + agitation +
insomnia
– Functional impairment – boredom – agitation
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
A Contextual Model for Symptom
Management for AD
• Processes at each level influence the next
level
• Four quadrants direct symptom
management
– Caregiving environment
– Social environment
– Physical environment
– Medical treatment
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
A Contextual Model for Symptom
Management for AD
• Nurse-directed care
– Approach focuses on prevention
– Nurses provide and suggest behavioral
strategies
– Add pharmacological interventions as last
resort
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OUTCOME 5
Discuss Parkinson disease in terms of
diagnosis, treatment strategies, and nursing
interventions.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Parkinson Disease
• Cause
– Loss of nerve cells
– Decreased dopamine
– Altered ratio of dopamine to acetylcholine
– Exact cause unknown
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Risk Factors
• Aging
• Equality noted between races and sexes
• Genetics
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Diagnostic Testing
• No specific testing
• Diagnosis made by excluding other
possibilities
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Characteristics of Parkinson
Disease Stages
• Early stage
– One-sided symptoms
– Changes in posture, walking, and facial
expression
• Middle stage
– Difficulty rising from sitting position
– Maintain a flexed posture
• Late stage
– Inability to stand or walk
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pharmacological Therapies
•
•
•
•
Sinemet
Anticholinergics
Amantadine
Dopamine agonists
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Surgical Management
• Unilateral posteroventral pallidotomy or
thalamotomy
• Brain stimulation surgery
• Transplantation of fetal midbrain
dopaminergic cells
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Care
•
•
•
•
Promote mobility
Prevent falls
Preserve independence
Exercise
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OUTCOME 6
Define brain attack/stroke.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Stroke
• Rapid onset
• Loss of consciousness
• Results from a lack of blood perfusion to
the brain
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Transient Ischemic Attack (TIA)
• Often called a “mini-stroke”
• Causes no permanent damage
• Increases risk of stroke in the future
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Causes of Strokes
• Hemorrhage into the brain
• Embolus or thrombus that occludes an
artery
• Rupture of an extracerebral artery
resulting in subarachnoid hemorrhage
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OUTCOME 7
Discuss brain attack/stroke in terms of highrisk older persons, treatment, and nursing
implications.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Strokes
• A leading cause of death
• 12:10,000 Americans will have a stroke
each year
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Strokes
• Risk factors
– Hypertension
– Smoking
– Sedentary lifestyle
– Obesity
– Diabetes mellitus
– Excessive alcohol consumption
– Elevated cholesterol levels
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Strokes
• Prevention
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–
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Balanced diet and weight loss
Exercise
Tight glycemic control
Reduction of high-risk behaviors
Carotid endarterectomy: is a surgical procedure used
to prevent stroke, by correcting stenosis (narrowing)
in the common carotid artery. Endarterectomy is the
removal of material on the inside (end-) of an artery.
– Anticoagulant therapy
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Strokes
• Treatment
– Establish airway
– Ventilation and oxygenation
– Assess neurological status
– Vital signs
– Rehabilitation
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OUTCOME 8
Discuss nursing interventions for seizures.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Care of the Patient with
Seizures
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Obtain medical history
Review history of seizures
Medication use
Patient-family education
Prevention of injury
Monitor for status epilepticus
Documentation
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OUTCOME 9
Discuss the difference between epilepsy and
seizures and nursing implications.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Seizure
• Abnormal, abrupt release of electrical
activity in the brain
• Results in a variety of symptoms
(spasticity, flaccidity)
• Manifestations based upon area of brain
affected
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Epilepsy
• Two or more unprovoked seizures
• Incidence increases with age
– People older than 75 twice as likely to
develop new-onset epilepsy
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.