Transcript Slide 1

Neurologic Trauma
8-10 Questions
Monti Smith, MSN, RN
Increased Intracranial Pressure
• The cranial vault contains:
– Brain tissue
– Blood
– Cerebrospinal fluid
– These three things give your brain a state of
equilibrium
• Monro-Kellie Hypothesis - ↑ in any of the
cranial vault components causes a change
in the volume of the others by displacing
or shifting CSF, ↑ CSF absorption or ↓
blood volume
Pathophysiology of ICP
• Normal ICP is 10 – 15 mm Hg
• Most commonly associated with head
injury
• Secondary effect in conditions such as:
– Brain tumor
– Subarachnoid hemorrhage
– Encephalopathies
• ↑ ICP affects cerebral perfusion, produces
distortion, and shifts brain tissue
Pathophysiology cont.
• Reduced cerebral blood flow results in
ischemia
• Complete ischemia for > 3-5 mins. results
in irreversible damage
• Early stages of ischemia - vasomotor
centers are stimulated resulting in a slow
bounding pulse & respiratory irregularities
Pathophysiology cont.
• CO2 concentration regulates cerebral
blood flow – rise causes dilation
whereas a fall vasoconstricts
• Cerebral edema occurs when there is
↑ in water content of the brain tissue
Pathophysiology – Cerebral
Response to ↑ ICP
• Autoregulation – the brain’s ability to
change the diameter of its blood vessels
automatically for maintenance of constant
cerebral blood flow
• Cushing’s response – the brain’s attempt
to restore blood flow by increasing arterial
pressure to overcome increased
intracranial pressure
Decompensation Phase
• Exhibit changes in mental status & V/S –
Cushing’s triad:
– Bradycardia
– Widening pulse pressure/hypertension
– Respiratory changes
• Herniation of brain stem + occlusion of
cerebral blood flow = cerebral ischemia &
infarction = leading to brain death
If there is a Q on the test:
• What you would look for in the question,
do they have these three things:
– Far apart BP
– Pulse in the 50’s
– Temp would be high
Clinical Manifestations of ↑ICP
• Change in level of responsivenessconsciousness
– The most important indicator of the pt’s condition
• Any sudden change in condition has
neurologic significance:
– Restlessness without cause
– Confusion
– ↑ drowsiness
Complications of ↑ICP
• Brain stem herniation
– Not much you can do for this
• Diabetes insipidus
– Treat with fluid, check on lyte’s
• Syndrome of inappropriate
antidiuretic hormone
– Restrict fluids
Management of ↑ICP
• ↑ICP is a true emergency a treat promptly
• Goal – ↓ cerebral edema, lowering volume
of CSF, or ↓ blood volume while
maintaining cerebral perfusion
• Administer osmotic diuretics to dehydrate
brain & reduce cerebral edema
– Mannitol
– Glycerol
Nursing Diagnoses
• Ineffective airway clearance
– Diminished cough and gag reflexes
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Ineffective breathing patterns
Ineffective cerebral tissue perfusion
Deficient fluid volume
Risk for infection
– b/c of hole they put in head to monitor
pressure
What Can The Nurse Do?
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Maintain airway & monitor breathing
Maintain proper positioning
Maintain proper fluid balance
Monitor for s/s of infection
Monitor for potential complications
– Stool softeners to prevent straining during a
poo
– Keep an emotional/stress free environment
Management of ↑ICP
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Foley catheter to monitor urinary output
Serum osmolality levels to assess hydration
Corticosteriods to help reduce edema
Maintain cerebral perfusion by using fluid volume
& inotropic agents
• Reduce CSF & blood volume by draining CSF
• Control fever to ↓ rate at which cerebral edema
forms
Head Injuries
• Trauma to scalp, skull, or brain
– Primary: initial damage to the brain (like you get
hit in the head with a hammer)
– Secondary: evolves over hours & days after the
injury (like Liam Neeson’s wife)
• An injured brain is different than other injured
body parts because of its location!
– There is no where for the swelling and all that to
go, so the pressure just increases and is super
bad news
• Scalp injuries – causes lots of bleeding, but
usually minor
Types of Force
• Acceleration injury
– Head in motion
– Like in a car wreck
• Deceleration injury
– Head suddenly stopped
– Like if you’re sitting stopped in your car and
someone hits you
Skull Fractures
• Break in the continuity of the skull caused by
a forceful trauma
• Fracture may be open or closed
– Open is if you have any tear in the dura
– Closed is when the dura is still intact
• Types of Fractures
– Simple – a clean break, straight little line
– Comminuted – a splintered break or there are
multiple fracture lines
– Depressed – bone fragments that are depressed
or imbedded into the brain tissue
– Basilar – fracture at the base of the skull
Clinical Manifestations
• Dependent on severity and distribution of
brain injury
• Persistent, localized pain suggest fracture
• X-ray needed for diagnosis
• Basilar skull fracture frequently produces
hemorrhage and CSF leakage
• Bloody CSF suggests brain laceration or
contusion
Assessment & Diagnostics
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Physical Exam & Neuro status
CT scan
MRI
Cerebral angiography
Medical Management
• Close observation if nonsurgical
– HOB is usually 30 degrees
• Surgery for depressed fractures
– IV antibiotics for these guys
• Monitor for CSF leakage
– Might leak out ears (otorrhea) and nose
(rhinorrhea)
– Get some sterile gauze and place it with some
tape under their nose. Tell the pt not to be
blowing their nose
Traumatic Brain Injury
• Occurs as a result of an external physical
force that may produce a diminished or
altered state of consciousness
• The brain responds to forces by forward
movement within the cranial vault
• Motor vehicle crashes are the most
common cause
• The cognitive impairment that they suffer
from that is usually irreversible
Battle Sign
• Like a bruise or whatever behind their ear.
This is a good indicator that they hada
basilar skull fracture. This is a good
assessment.
Primary Brain Injury
• Results from physical stress within the brain
tissue caused by open or closed trauma
• Open head injury – occurs with skull fracture or
penetration of the skull
– The brain has been exposed to the
outside/environmental contaminants. Not too good…
Damage that occurs to the vessels, sinuses, cranial
nerves, anything like that
• Closed head injury – result of blunt trauma and
is more serious
– You’re hit really hard and your brain gets squished.
You can’t really go in and repair anything.
Types of Brain Injuries
• Concussion – minor, client may or may not lose
consciousness, causes no structural damage
– These guys should go to the hospital to make sure it’s not
something more serious, but generally these people will be sent
home and be given instructions to stay awake or woken often if
they do sleep. Make sure they’re not confused, vomiting, c/o
weakness or HA, etc. This is important b/c these are signs of
internal damage. Usually take a few days to get over
• Contusion – major, client loses consciousness, brain is
bruised
– This pt may lose consciousness for a few mins, usually have a
decrease in BP, respirations, can lose control of their
bowel/bladder. Usually when they go unconscious you can
usually easily rouse them, but they’re very hyperactive when
they get up (like all jumpy and what-not). Usually take several
months to get over. Client may be left with HA, vertigo, seizures
after the contusion.
Epidural Hematoma
• Results from arterial
bleeding into the
space between the
dura and inner
surface of the skull.
• Often these are
caused by fractures of
the temporal bones.
The break can cause
a tear to the artery
right there and it will
form quickly
Epidural Hematomas
• Initial s/s:
– They go unconscious then they have a brief
period of lucidity followed by a decreased
LOC
– This is a medical emergency! This person can
have respiratory arrest w/I minutes!
– For this person they go in and drill holes to
decrease the ICP. If there’s a clot they go in
and remove it. If there is a bleed they’ll go and
try to stop it. Might put in a drain to prevent
reacumulation of the blood
Medical Management
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MEDICAL EMERGENCY!!!!!
Burr holes through skull
Possible craniotomy
Drain
Subdural Hematoma
• Results from venous
bleeding into the space
beneath the dura and
above the arachnoid
• Most common cause is
trauma. Can be caused
by bleeding disorderes
or ruptured aneurysms.
Most are venous
(caused by ruptures of
small vessels). Arterial
ones are more rapid.
Types of Subdurals
• Acute – occur with major head trauma, s/s
develop over 24-48 hours.
– S/S changes in LOC
• Subacute – occur with less severe contusions,
s/s develop 48 hours-2 weeks
– S/S changes in LOC
• Chronic – occur with minor head injuries, s/s
develop 3 weeks-3 months, most frequently
seen in the elderly (we get older and our brain
shrinks in our skull that stays the same size).
Harder to diagnose. Symptoms can mimic
dementia or Alzheimer's
Intracerebral Hemorrhage
• Accumulation of blood within
the brain tissue caused by
tearing of small arteries and
veins in the white matter
• Direct trauma (fractures and
things, bullet wounds, stab
injuries). You’ll see it a lot if
someone has a tumor that
bleeds all around it. High BP
can cause this, anticoagulation therapy people
who fall and hit their heads,
bleeding disorders
Medical Management of Brain
Injuries
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Physical & neurological exam
CT & MRI scans
Ventilatory support
Seizure prevention
Fluid & electrolyte maintenance
Nutritional support
Management of pain & anxiety
What Is The Nurse’s
Responsibilities?
• Ongoing neurological assessment
– LOC
– VS
– Motor function
– Pupil size
Cerebrovascular Disorders
(6-8 Questions)
Monti Smith, MSN, RN
Stroke
• Definition – A disruption in the normal
blood supply to the brain
• Medical emergency. Needs to be treated
immediately, the longer it lasts the worse
the symptoms are
• 3rd most common cause of death in the
United States
• Primary cause of adult disability in the
United States
Types of Strokes
• Ischemic
– Thrombotic
– Embolic
– Transient Ischemic Attack
• Hemorrhagic
Thrombotic Stroke
• Results from thrombosis or narrowing of a
blood vessel
• Most common cause of strokes
• Associated with DM & HTN
• Can be preceded by a TIA
• Usually don’t lose consciousness in the
first 24 hours
Embolic Stroke
• Embolus dislodges & occludes a cerebral
artery resulting in infarction & edema
• Second most common cause of stroke
• Mostly originates from the endocardial
layer of the heart
• Lodges wherever the vessel narrows or
where it bifurcates
• If we don’t treat the underlying cause of
these kinds of strokes or else it is almost
certainly going to happen again
Hemorrhagic Stroke
• Caused by bleeding into the brain tissue,
ventricles, or subarachnoid space
• Causes can vary
– HTN, aneurysms, bleeding tumors…
– You don’t want these kinds of strokes. If you
survive the acute phase you’re going to have
major problems
• Deficits are severe & recovery is long
Transient Ischemic Attack (TIA)
• Temporary loss of neurologic function
caused by ischemia
• Can last from 15 minutes to 24 hours
• Serve as a warning sign of further
cerebrovascular disease
• Complete recovery between attacks
Clinical Manifestations
• Motor deficits
– Hemiparesis
– Hemiplegia
– Ataxia
• Communication
– Dysarthria
– Dysphagia
– Aphasia
• Expressive Aphasia – their brain is thinking correctly
but the words are coming out wrong. They know what
they want to say but can’t get it out
• Receptive Aphasia – they get confused by what you
say. On the way from the ear to the brain the msg gets
messed up. It never gets
Clinical Manifestations cont.
• Cognitive Impairment
– Memory loss
– ↓ attention span
– Poor reasoning
– Altered judgment
• Psychological Effects
– Loss of self-control
– Depression
– Emotional lability
Clinical Manifestations cont.
• Perceptual Disturbances
– Homonymous hemianopsia
• Loss of half of your visual field
– Loss of peripheral vision
– Diplopia
– Difficulty judging distances
– Apraxia
• Inability to perform a previously learned action
Assessment & Diagnostic Findings
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History, assessment, neuro exam
CT without contrast
EKG
Carotid doppler
May also see
– Cerebral angiogram
– Transcranial doppler
– Transesophageal echocardiography
• Put scope down throat to look at the back of your heart. A
regular echo can’t see the back of the heart.
– MRI
Medical Management for Acute
Stroke
• Thrombolytic Therapy within 3 hours of s/s
– Noncontrast CT of head
• Looking for blood. If they have blood it means it
might be a hemorrhagic stroke and you don’t want
to give them things that are going to increase their
risk of bleeding
– Blood tests for coagulation studies
– Screening for hx of GI bleeding in past 3
months or major surgery in last 14 days
Surgical Management
• Carotid endarterectomy
– Go in and clean out the carotid arteries of
plaque and stuff
• Carotid stenting
– Don’t see this alone as much. May do the
cleaning and stenting at the same time
• Aneurysm clipping, coiling
• Resection of arteriovenous malformation
(AVM)
Medical Management
• Prevention is the most important!
• What are some modifiable risk factors?
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HTN
Afib
↑ Lipids
DM
Smoking
Carotid stenosis
Obesity
Excessive alcohol consumption
Medical Management
• Coumadin for atrial fibrillation
• Plavix, ASA, Ticlid for TIA’s and strokes
from suspected embolic or thrombotic
causes
• Statins
– For cholesterol
• Antihypertensives
Acute Nursing Interventions
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Support respiratory system
Frequent neuro exam
Monitor cardiovascular system
Monitor musculoskeletal system
Monitor for skin breakdown
Monitor for constipation
Promote normal bladder function
Right after they’ve had the stroke be super
nice to them
• Then in rehab we are harder on them. Boot
camp kind of thing.
Acute Nursing Interventions cont.
• Assess & monitor nutritional status
• Be supportive with communication efforts
• Initially arrange client’s environment within
their perceptual field
– Use their good eye, so to speak
• Give client & family clear &
understandable explanations regarding
situation and procedures
Nursing Diagnoses for Patients
with Stroke
• Impaired physical mobility R/T hemiparesis,
loss of balance and coordination, spasticity,
and brain injury
• Acute pain (shoulder) R/T hemiplegia and
disuse
• Self-care deficits R/T stroke sequelae
• Disturbed sensory perception R/T altered
sensory reception, transmission
• Impaired swallowing
Nursing Diagnoses
• Incontinence R/T flaccid bladder,
detrusor instability, confusion, or
difficulty communicating
• Disturbed thought processes R/T brain
damage, confusion, or inability to follow
instructions
• Impaired verbal communication R/T
brain damage
Nursing Diagnoses
• Risk for impaired skin integrity R/T
hemiparesis/hemiplegia, or ↓ mobility
• Interrupted family processes R/T
catastrophic illness and caregiving
burdens
• Sexual dysfunction R/T neurologic
deficits or fear of failure
Goals for Patient & Family
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Improvement of mobility
Avoidance of shoulder pain
Achievement of self-care
Attainment of bladder control
Improvement of thought processes
Achievement of some form of communication
Maintenance of skin integrity
Restoration of family functioning
Absence of complications
Achieve Self-Care
• Encourage to assist in personal hygiene as
soon as able to sit up
• Start with affected side
• Dressing - better balance in seated position
• Improves morale if fully dressed
• Use clothing size larger than normal
• Place on affected side - dress first
Attain Bladder Control
• Offer urinal/Bedpan on schedule
• Upright posture & standing position for
males
Achieve Communication
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Speech-language therapist to assess needs
Be sensitive to reactions & needs
Always treat patient like an adult
Lend strong moral support
Consistent schedule, routines, & repetition
Surround with familiar objects
Have attention, speak slowly, one at a time
Maintain Skin Integrity
• Emphasis on bony areas & dependent
parts
• Specialty bed during acute phase
• Regular turning & positioning schedule
• Keep skin clean & dry
• Gentle massage of healthy skin
• Adequate nutrition
Improve Family Coping
• Family plays important role in recovery
• Involve them in patient’s care
• Need to avoid doing for patient what
patient can do for himself
• Inform them rehab is long & progress may
be slow
Sexual Dysfunction
• Profoundly altered by disability
• Often experience loss of self esteem &
value
• Encourage to keep active, adhere to
exercise program, continue to remain self
sufficient
• May benefit from sexual counseling
Home Care Planning
• May require speech therapist &
occupational therapist
• Emotionally:
– tires easily
– will become irritable & upset at small things
– likely to show less interest in things
– depression is common
Home Modification
• OT assess home environment &
recommends modifications
• Shower - sitting on stool
• Long-handled bath brush
• Portable shower hose
• Handrails
Communication
• Speech-language pathologist assess
ability to communicate
• Nursing - includes listening, asking to
follow simple directions, & observing cope
with dysfunction
Continued Management
• Promoting positive self-esteem
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Give as much psychological security as possible
Patience & understanding while learning to speak
Treat patient as adult - use kind, unhurried manner
Accept patient’s behavior & feelings
Avoid completing thoughts & sentences for patient
Environment should be relaxed & permissive
Encourage to socialize with family/friends
Critical Thinking
• The nurse planning care for a client who suffered
a cerebrovascular accident (CVA) with residual
dysphagia would write on the care plan to avoid
doing which of the following during meals?
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(A) Feed the client slowly
(B) Give the client thin liquids
(C) Give foods with the consistency of oatmeal
(D) Place food on the unaffected side of the mouth
Brain Tumors
• Definition: A localized intracranial
lesion that occupies space within the
skull.
• Tumors usually grow as a spherical
mass but can grow diffusely,
infiltrating tissue.
Brain Tumors
• Primary
– Originate within the CNS
– Cause unknown – possibly genetics, defective
immune system, heredity, viruses, head injury
• Secondary/Metastatic
– Develop from structures outside the brain
– Lesions occur commonly from lung, breast,
lower GI, pancreas, kidney, skin
Gliomas
• Most common brain neoplasm – about
60% of all brain tumors
• Spread by infiltrating into surrounding
neural tissue
• Total removal causes considerable
damage to vital structures
• Astrocytomas – most common type
Pituitary Tumor
• Most common is Adenoma
– 10 – 25% of all brain tumors
– Symptoms are caused by pressure on adjacent
structures or hormonal changes
– Pituitary gland AKA hypophysis
Menigioma
• Encapsulated, globular, and well
demarcated
• Causes compression and displacement of
surrounding brain tissue
• Tends to recur
Acoustic Neuroma
• AKA cerebellar pontine angle tumors
because of anatomic location.
– On the 8th cranial nerve
• More prevalent in females
• Common symptoms: hearing loss,
tinnitus, and dizziness
Clinical Manifestations of Brain
Tumors
• Symptoms of increased ICP
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Headache
Vomiting
Papilledema
Personality changes
Focal deficits
• Motor
• Sensory
• Cranial nerve dysfunctions
Diagnostic Findings
• CT Scan, MRI, PET Scan
• Stereotactic biopsy – diagnoses deep-seated
brain tumors
• Cerebral Angiography – for visualization of
cerebral blood vessels
– Because sometimes tumors are very vascular and
they don’t want to cut it out before they get rid of the
vessels cause you might bleed to death
• EEG – Detects abnormal brain waves and
temporal lobe seizures
• Cytologic studies of CSF – detect malignant
cells
Treatment Modalities
• Transsphenoidal microsurgical removal
– Up your nose. Take the tumor out of your nose!
Eww
• Radiosurgery with a Gamma Knife – delivers
high dose of radiation – no surgical incision
• Stereotactic – Laser or radiation delivery –
Implantation of radioisotopes
• External-beam radiation
• Brachytherapy – surgical implantation of
radiation sources
Nursing Management
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Monitor patient for aspiration (surgical)
Monitor for ↑ICP
Frequent reorientation may be required
Monitor patients with seizure history
Assess motor function
Assess speech
Pupillary size and reaction may be affected by
cranial nerve involvement
Cerebral Metastases
• Metastatic brain lesions constitute 10% of all
intracranial tumors
• Cerebral Metastases is most common
• Signs and Symptoms include:
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Headache
Paralysis
Seizures
Aphasia
• Focal Weakness
• Altered Mentation
• Personality Changes
Medical Management
• Palliative treatment
• Surgery
– Treatment of choice for brain tumors
• Radiation therapy
• Chemotherapy
• Corticosteroids – headaches (to decrease chance of
HA)
• Osmotic agents – decrease IOP (i.e. manitol)
• Anticonvulsants
• Analgesics
• You probably won’t see chemotherapy IV because
chemotherapy can’t cross the BBB
Seizures & Headaches
(8-10 Questions)
Monti Smith, MSN, RN
Seizure Disorders
• Definition – An abnormal, sudden,
excessive discharge of electrical activity
within the brain
• Causes vary and are classified as:
– Primary/Idiopathic – no identifiable cause
– Secondary – hypoxemia, fever, head injury,
hypertension, CNS infections, metabolic/toxic
conditions, brain tumor, drug withdrawal,
allergies
Seizures
• Six types of generalized seizures
– Tonic-clonic
• Generalized seizures, also called Grand Mauls or whatever.
2-5 minutes, person goes rigid, LOC, incontinence. After they
come around they’re confused and all that mess
– Absence
• They just stare off, usually last seconds
– Myoclonic
• Brief jerking or stiffening of the extremities. Usually last for a
few seconds.
– Atonic/Akinetic
• Lost of muscle tone, may fall down.
– Clonic
– Tonic
Seizures
• Partial or Focal
• Two main classes
– Complex
• Psychomotor
• Temporal lobe seizures
– Simple
Seizures
• Unclassified/Idiopathic
– Account for about half of all seizure activity
– Occur for no known reason
– Do not fit generalized or partial classification
Seizures
• Patient may have memory loss during seizure
activity & a short time thereafter
• Brain damage may occur when seizures are
severe or prolonged
• Risk for hypoxia, vomiting, pulmonary aspiration,
persistent metabolic abnormalities
• Goal of treatment is control of the seizure and
determination and control of the cause long-term
– If we can figure out what’s causing it and treat that
then we have a good chance of getting rid of these
guys
Management
• Management meets individual patient
needs not just manage and prevent
seizures
• Drug therapy – goal is to achieve
seizure control with minimal side effects
• Drug therapy controls rather than cures
Status Epilepticus
• Definition – Acute prolonged seizure activity
– Either last 30 mins or seizure after seizure after seizure
after seizure after seizure and so on
– The brain isn’t getting any oxygen during this time
• Considered a major medical emergency
• Produces cumulative effects
• Repeated episodes of cerebral anoxia & swelling
may lead to irreversible & fatal brain damage
• Goal of management is to stop the seizures as
quickly as possible, ensure adequate cerebral
oxygenation, and maintain a seizure-free state
Seizure Treatment
• Vagal Nerve Stimulation (VNS)
– Controls medically intractable simple or
complex partial seizures
– Appropriate for persons not candidates for
surgical intervention
– Appropriate for persons not controlled by less
invasive treatment options
– Surgically implanted in the left chest wall
– Activated to deliver intermittent VNS
Headache
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One of the most common complaints
More of a symptom than disease
Stress response
Vasodilation
Skeletal muscle tension
Types of Headaches
• Primary – no organic cause
– Migraine
– Tension
– Cluster
– Cranial arteritis
• Secondary – associated with a cause
– Brain tumor
– Aneurysm
Migraines
• Recurring vascular-type headache characterized
by unilateral or bilateral throbbing pain
• Cause not clearly demonstrated
– Occurs more commonly in women
– Strong familial tendency
– Typical time of onset is puberty
– Highest incidence ages 20 – 35
Types of Migraines
• Migraine with aura
– Visual disturbances
– Parasthesias
– Motor dysfunctions
• Migraine without aura
Clinical Manifestations
• Usually begins on awakening but can
occur any time
• Migraine is divided in 4 phases
– Prodrome
– Aura
– The headache
– Recovery
Clinical Manifestations
• Prodrome Phase
– Experienced by 60%
– Symptoms occur hours to days before headache
• Depression
• Irritability
• Feeling cold
• Food cravings
• Anorexia
• Activity level changes
Clinical Manifestations
• Aura Phase
– Occurs in about 20%
– Lasts less than an hour
– Focal neurologic symptoms
– Visual disturbances
– Numbness and tingling in lips, face, or hands
– Mild confusion
– Slight weakness of an extremity
– Drowsiness or dizziness
Clinical Manifestations
• Headache Phase
– Vasodilation and serotonin level declines
– Throbbing headache, severe and
incapacitating
– Photophobia
– Nausea/Vomiting
– Duration 4 – 72 hours
Clinical Manifestations
• Recovery Phase
– Pain gradually subsides
– Muscle contraction in the neck and scalp are
common
– Muscle ache and local tenderness
– Exhaustion
– Mood changes
– Physical exertion exacerbates pain
– Extended sleep may occur
Medical Management
• Therapy is abortive or preventive
• Abortive (symptomatic)
– Best for frequent attack sufferers
– Aim at relief or limiting headache at onset or
while in progress
• Preventive
– Frequent attacks at regular or predictable
intervals
– Would take these on a daily basis
Medical Management
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Serotonin receptor agonists
Most specific anti-migraine agents available
Cause vasoconstriction
Reduce inflammation
May reduce pain transmission
Examples
– Ergotamine
– Sumatriptan
– Dihydroergotamine
Medications
• Ergot Alkaloids
– Ergotamine
– Dihydroergotamine
• Triptans
– sumatriptan (Imitrex)
Prophylactic Treatment
• Antiepileptics
– Topamax, Depakote, Valproic Acid
• Antidepressants
– Amitriptyline, nortriptyline
• Antihypertensives
– Propranolol, Verapamil, Lisinopril,
Candesartan
• Botulinum toxin A (Botox)
Alternative Treatment
• Biofeedback
• Behavioral therapy
• Herbs
– Feverfew
– Petasites hybridus (herb Butterbur)
• Acupressure/acupuncture
• Massage/chiropractic
• Exercise
Migraine Triggers
• Menstrual cycles
• Overuse of certain
meds
• Foods with
tyramine
• Milk products
• Aged cheese
• Wine & Chocolate
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Fatigue
Nitrites
Bright lights
Sleep deprivation
Depression
Processed foods
Monosodium
Glutamate
Nursing Management
• Goals
– Administer medications to treat acute
event
– Prevent recurrent episodes
• Patient education regarding precipitating
factors
• Possible lifestyle or habit changes
• Pharmacologic measures
Relieving Pain
• Early phase requires abortive
medication therapy ASAP
• Ongoing phase includes
– Comfort measures
– Quiet room/area
– Dark environment
– Elevate HOB 30 degrees
– Antiemetics as needed
Cluster Headache
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Severe form of vascular headache
Most frequent in males ages 20 – 40 years
Unilateral coming in clusters of 1 – 8 daily
Watering of the eye and nasal congestion
Attacks last 15 mins. to 3 hrs.
May have crescendo – decrescendo
pattern
• Described as penetrating and steady
Clinical Manifestations
•
•
•
•
•
•
•
Excruciating pain (boring or piercing in nature)
Orbital or supraorbital pain
Eye tearing
Tenderness of the temporal artery
Facial flushing
Elevated skin temperature on the ipsilateral side
Very restless behavior
Precipitators
•
•
•
•
Alcohol
Nitrites
Vasodilators
Histamines
Medical Therapy
• Medication therapy
– Triptans
– Tricyclic antidepressants &
vasoconstrictors
– 100% oxygen @ 7 – 9 l/min for approx.
15 mins.
– Exercise
• Prophylactic therapy
– Calcium channel blockers (verapamil)
– Corticosteroids (prednisone, solumedrol)
Cranial Arteritis
• Inflammation of cranial arteries
• Severe headache localized in region of
temporal arteries
• Inflammation may be generalized
(vascular disease)
• Inflammation may be focal (cranial
arteries)
• Older population – greatest incidence >70
Clinical Manifestations
•
•
•
•
•
Fatigue
Malaise
Weight loss
Fever
Inflammation – heat, redness, swelling,
tenderness, or pain over affected artery
• Visible nodular temporal artery may occur
• Visual problems from ischemia
Treatment
• Corticosteroids to prevent loss of vision
due to vascular occlusion or rupture of
involved artery
• Patient teach: Abruptly stopping
medication can lead to relapse
• Analgesics for comfort
Tension Headache
• Contraction of the muscles in the neck and
scalp
• Most frequent cause is stress
• Steady, constant feeling of pressure
• Described as band-like or a weight on top
of the head
• Chronic rather than severe
• Probably most common type of headache
Nursing Considerations
• Reassurance that the cause is not a brain tumor
• Employ stress reduction techniques
– Biofeedback
– Exercise
– Meditation
• Symptomatic relief of symptoms
– Local heat
– Massage
– Analgesics, antidepressants, muscle
relaxants
Neurologic Infections,
Autoimmune Disorders, and
Neuropathies
15-20 Questions
Monti Smith, MSN, RN
Neurologic Infections
• Meningitis
• Brain Abscess
– Infectious material in the brain
• Encephalitis
Meningitis
• Inflammation of the meningeal tissues
• Classified as:
– Bacterial – gains access through bloodstream,
wounds of the skull, & fractures to the skull or
sinuses
• Can be deadly!
– Viral – cause is viral or secondary to lymphoma,
leukemia, or HIV
• Commonly seen in colleges, military bases,
etc. More common in the winter (b/c that’s
when you typically get more infections)
Clinical Manifestations
•
•
•
•
Headache
Fever
Nuchal rigidity
Positive Kernig’s sign
– When the pt is lying with their knee up to their
stomach. The leg can’t be completely extended.
• Positive Brudzinski’s sign
– When you flex their neck, their knees and hips
flex as well
• Photophobia
Autoimmune Disorders
• Multiple Sclerosis
• Myasthenia Gravis
• Guillain-Barré Syndrome
Multiple Sclerosis
• A progressive, degenerative disorder
characterized by demyelination of nerve
fibers of the brain & spinal cord
• Cause is unknown, but thought to be
related to genetics, infection, & immunity
• Affects mostly women between 20-40
• Characterized by periods of remission and
exacerbation
• Seen more in cold climates
Types of Multiple Sclerosis
• Relapsing-remitting
– Most common
– These pts will tend to experience series of attacks or
exacerbations followed by complete or partial remission
• Primary progressive
– Disease shows progression from onset with occasional plateaus
and temporary minor improvements
– As soon as a pt finds out they have MS it is progressing
• Secondary progressive
– Chronic progressive form. No real periods of remission
– Small breaks with some relief
• Progressive-relapsing
– Worst one. Most commonly found in men
– Characterized by gradual decline, no real periods of remission
Early Symptoms
(Common early S/S)
•
•
•
•
Tingling (lasts a few days usually)
Numbness (lasts a few days usually also)
Loss of balance
Blurred or double vision (very common. A
lot of times people will go to the eye dr for
this and the eye dr guy sends them in to
be checked for MS)
• Weakness in one or more limbs
Clinical Manifestations Motor
• Fatigue and stiffness of extremities
– Spacticity
• Hyperactive deep tendon reflexes
• Positive Babinski’s reflex
• Visual difficulties
– Could be blurred vision, double vision, decreased visual
acuity, nystagmus (googly eyes)
• Intention tremor
– I don’t usually have a tremor all the time, but when I go to
perform an activity (like picking up a cup) I get the tremor
• Unsteady gait
• Dysmetria
– Inability to direct or limit movement. Like I want to go one
way but I can’t
Clinical Manifestations Sensory
•
•
•
•
•
Facial pain
Numbness
Tingling
Burning
Bladder function changes
– Can be urgency, frequency, having to pee a lot at
night
• Bowel function problems
• Problems with sexuality
– Impotence, decreased vaginal secretions, etc.
Clinical Manifestations
Cognitive
•
•
•
•
•
Inattentiveness
Impaired judgment
Decreased concentration
Decreased short-term memory
Decreased ability to perform calculations
Assessment & Diagnostic Findings
• MRI
– They are looking for Demylenating plaques
(called MS plaques) in the brain, neck, and spine.
A lot of the times you can tell from the symptoms
where the problem might be. Vision problems =
head. Tingling = neck. Leg problems = spine.
• CSF analysis
• Evoked potential studies
• Neuropsychological testing
– How bad are your cognitive impairments?
• Sexual history
Medical Management
• No cure
• Goals of treatment: delay progression of
disease, manage chronic symptoms, & treat
acute exacerbations
• Management strategies target various motor
& sensory symptoms & effects of immobility
– Some people may only take one thing a week to
prevent progression while not in an exacerbating
stage. Others have to be on super tons of stuff all
the time. It just depends on the person
Pharmacologic Treatment
• Disease-modifying
– Betaseron, Avonex, Rebif, Copaxone,
Novantrone, Methylprednisolone
• Symptom management (spasticity)
– Baclofen
– Valium
– Zanaflex
– Dantrium
Pharmacologic Treatment Cont.
• Symptom management (urinary problems)
– Urecholine
– Prostigmin
– Ditropan
• Symptom management (CNS stimulants)
(to try and fight the symptoms of fatigue)
– Cylert
– Ritalin
– Provigil
– Amantadine
Nursing Interventions
• Promote physical mobility
– Walking, stretching, swimming, stationary bikes. Do things that aren’t
strenuous because the quick stuff can make their spasticity worse
(which is bad). Plan rest and activity accordingly
– MS pt’s do poorly if their body temp goes up. The higher the temp, the
worse their symptoms.
• Prevent injury
– MS causes a lot of problems with incoordination and their gate. They
may have to use assistive device
• Enhance bowel & bladder control
– May require training
• Enhance communication
– Like for someone in a progressive form, might have problems with their
communication. She hasn’t really seen this
• Improve sensory & cognitive function
• Teach about medications
• Educate family
Myasthenia Gravis
• Definition – An autoimmune disease that involves a
decrease in the number and effectiveness of
acetylcholine receptors at the neuromuscular junction
– Antibodies are found in 80-90% of people with myasthenia
gravis (MG)
– 80% of pt’s diagnosed with MG end up having thymus
gland problems (could be hyperplasia or a tumor which is
called a thymoma)
• Thymus gland is believed to be where these antibodies are
produced
• Etiology – Although unclear, research strongly
suggests cause is antibodies to acetylcholine
receptors
• When someone has MS their immune system makes
antibodies that damage or block many of the muscles’
acetylcholine receptors. The effected muscles don’t
work as well as they would normally if they had all the
acetylcholine receptors…
Incidence of MG
•
•
•
•
•
Not hereditary
May have 5% familial incidence
Onset before age 10 or after age 60 is rare
Peak age between 20-30 years
Women affected 3 times more often than
men if onset before age 40
Clinical Manifestations
• Extreme skeletal muscle weakness
– Usually of the bigger muscles. May have trouble getting up from sitting.
Waxing/waning of this. Worsen with use and improves with rest. This is a
hallmark sign of the disease! Muscles are usually stronger in the morning
and weaker in the evening
•
•
•
•
Fatigability
Diplopia (double vision)
Ptosis (drooping of the eyelid)
Sleepy, mask like expression.
– Could have changes in expression or speech, difficulty with mastication
(chewing).
• Dysphonia (voice impairment)
• Extremity weakness
– Sometimes they can’t even keep their head up b/c their neck is super
weak
• Respiratory weakness
• Bulbar = the combination of the chewing, swallowing, speech stuff.
This could be bulbar weakness or whatever to describe weakness in
these three places
Diagnostic Findings in MG
• History & physical exam
• Tensilon test
– Tensilon facilitates the transmission of impulses at the myoneural junction leading to temporary improvement of symptoms.
It’s administered IV
– Their eye is droopy and you give them this and their eye isn’t
droopy anymore. Then after a few mins the eye is droopy again.
– Tensilon inhibits the breakdown of acetylcholine. It can cause Vfib and cardiac arrest. Make sure you have atropine in case that
happens and you need to give it!
• Acetylcholine receptor antibodies
– They take your blood and do a test. About 80-90% of pts with
MG will test positive for these guys
• Electromyography (EMG)
– Stick a needle in your muscle and they do tests and things to
see how your muscles are working…
• CT scan, MRI
Medical Management
• Anticholinesterase medications
– Mestinon
• Immunomodulating drugs
– Prednisone
• Cytoxic medications
– Imuran, Cytoxan, Neoral
Medical Management
• Plasmapheresis
– Used to treat exacerbations. Done IV. Take the plasma
and plasma components (kind of like dialysis). They
separate the blood cells and the antibodies, then they put
the blood back in. This simply reduces the number of
circulating antibodies. In about 75% of pt’s this gives them
great improvement, but it’s only temporary…
• IV immune globulin
– They don’t think it works that great, and it’s very
expensive. So they don’t do this much
• Thymectomy
– They go in and remove your thymus gland. It’s in your
chest, they have to go crack your ribs to remove it. Can
give you partial or complete remission. Can take up to 3
years to have the full effects from the surgery (for all the
antibodies to get out of your blood stream). Can combine
this with plasmapheresis to help…
Crises in MG
• Myasthenic Crisis
– Acute exacerbation of muscle weakness caused
by inadequate dose of anticholinergic
medications, infection, stress, or surgery
• Not enough
• Cholinergic Crisis
– Cause by overmedication with cholinergic drugs
• Too much
• Symptoms are the same in both so you can
tell the difference with a tensilon test.
Important to get a Hx
Nursing & Client Education
• Educate on importance of medication
management
• Teach energy conservation strategies
– B/c pt fatigues easily
– We need to encourage things like handicap stickers
– Tell them to do stuff when their strength is at it’s best
(usually in the mornings)
• Instruct on strategies to prevent ocular
manifestations
– Use eyedrops, wear patches at night to keep the
eyelids closed, surgery, etc.
• Educate on ways to minimize risks of aspiration
– Plan meal times around medications!
• Remind client of the importance of maintaining
health promotion practices
Nursing Diagnoses
•
•
•
•
•
•
•
Ineffective breathing pattern
Ineffective airway clearance
Impaired physical mobility
Impaired verbal communication
Constipation and other bowel dysfunctions
Self care deficit
Altered nutrition
Guillain-Barré Syndrome
• An acute inflammatory process characterized
by varying degrees of motor weakness and
paralysis
• An autoimmune attack on the peripheral
nerve myelin
• Mortality generally results from complications
of respiratory compromise
• Typically begins with muscle weakness and
starts at the bottom of the body
• Cause is unknown, but could be a viral
infection, trauma, surgery, or an
immunization, but who knows…
Clinical Manifestations
• Ascending weakness (starts at the bottom
and works it’s way up)
• Parasthesias, hypotonia, & areflexia (no
reflexes) of extremities
• May see bulbar weakness such as
paralysis of ocular muscles & inability to
swallow
• Worst case scenario: respiratory failure
• Weakness may start and then peak on the
14th day. Can be longer, can be shorter
Assessment & Diagnostic Findings
• History & physical
– Key is that it’s travelling up the body!
• Elevated protein in CSF
– They would find this during a lumbar puncture
• Abnormal EMG
– Reduced nerve conduction
Medical Management
• Airway maintenance (most important thing!!!! If they
have ascending paralysis it could paralyze their
diaphragm and if that happens then they can’t
breathe)
• Intravenous Immunoglobulin (IVIG)
• Plasmapheresis
• Provide range of motion for clients with decreased
mobility
• Prevent pulmonary emboli
• Encourage independence with ADL’s
• Most people recover b/w 6 months to a year. But it
can come back! That is a long recovery time.
Sometimes it plateaus 4 to 6 weeks, in some cases
1 year.
Nursing Diagnoses
•
•
•
•
•
Ineffective breathing pattern
Impaired physical mobility
Impaired verbal communication
Fear and anxiety related to paralysis
Imbalanced nutrition, less than body
requirements
Peripheral Neuropathies
• Disorder affecting the peripheral & sensory
nerves characterized by bilateral & symmetric
disturbance of function, usually beginning in the
feet & hands
• Symptoms: loss of sensation, muscle atrophy,
diminished reflexes, pain, & parasthesias
• Causes: systemic diseases, vitamin deficiency,
drug toxicity, infections, trauma, heavy metals,
and exogenous substances
Restless Legs Syndrome
• Characterized by leg parasthesias
associated with an irresistible urge to
move
• Common in iron deficiency, renal failure,
DM, rheumatic disorders, & pregnancy
• Complaints of intense burning or crawlingtype sensation
Management of RLS
•
•
•
•
•
•
Sinemet
Mirapex
Requip
Clonidine
Clonazepam
Some antiseizure meds
Cranial Nerve Disorders
• Trigeminal Neuralgia (Tic Douloureux)
– Very, very painful!!
• Affects the trigeminal or 5th cranial nerve
• Cause unclear: Suspect
– Compression of 5th nerve by a vein or artery
– Injury to the trigeminal nerve
– Herpes Virus (HHV6)
Managing Trigeminal Neuralgia
• Determined by amount of pain experienced.
Usually unilateral but can be on both sides
• Nonsurgical
– Carbamazepine
– Baclofen
– Amitriptyline
• Surgical
– Janetta procedure – arterial decompression
– Radiofrequency percutaneous electrocoagulation
Bell’s Palsy
• Definition – Acute paralysis of cranial
nerve VII (facial)
• Age is not a factor
• Onset is acute
• Maximal paralysis within 48 hrs – 5 days
• Cause – unclear – possibly result of
inflammatory process
Managing Bell’s Palsy
• Prednisone
• Analgesics for pain
• Avoid corneal abrasion by use of eye
ointments and patch or tape
• Use straws to diminish drooling
• Warm moist heat
• Facial exercises
• 80% full recovery
Degenerative Neurologic
Disorders
Parkinson’s Disease
• Definition – A slowly progressing neurologic
movement disorder eventually leading to
disability
• Degenerative or idiopathic form is most common
• Cause is unknown
• Research suggests: genetics, atherosclerosis,
excessive accumulation of oxygen free radicals,
viral infections, head trauma, chronic
antipsychotic medication use, environmental
exposures
– More men than women, symptoms usually show up in
the 50’s
Pathophysiology
• Associated with decreased levels of
dopamine
• Loss of dopamine stores result in more
excitatory neurotransmitters than inhibitory
neurotransmitters – imbalances that affect
voluntary movement
• Clinical symptoms appear with 60%
neuron loss and 80% dopamine decrease
Clinical Manifestations
• Classic Symptoms (triad)
– Tremor (often the 1st sign)
• Usually seen first at rest, and then aggravated by stress. Like a
booger rolling tremor
– Rigidity
• Increase resistance to passive motion. You try to move them and
they get stiff
– Bradykinesia
• Automatic movements are super slow. This accounts for their
stooped posture, shuffled gait. They also have no arm swings
when they walk
• Another important symptom
– Postural instability (propulsive gait, they lean too far forward
when they walk, like their balance is off. Their head is too far
forward and they lose their balance very easily)
• Other manifestations
– Shuffling gait
– Dysphonia
Other Manifestations
•
•
•
•
•
Excessive & uncontrolled sweating
Orthostatic hypotension
Gastric & urinary retention, constipation
Sexual dysfunction
Psychiatric disorders
– Depression, dementia, memory deficits,
personality changes. They have a lot of
hallucinations (can be b/c of meds)
• Sleep disorders
– A lot of times related to their medications
Diagnostic Findings
• Diagnosed clinically from patient history,
presence of 2 – 3 cardinal manifestations:
tremor, muscle rigidity, bradykinesia
• Family notices changes such as: stooped
posture, stiff arm, slight limp, tremor, handwriting
differences
• Medical history, presenting symptoms,
neurologic exam, & response to pharmacologic
management are carefully evaluated
Medical Management
•
•
•
•
•
•
Levodopa
Anticholinergics
Dopamine agonists
Monoamine Oxidase Inhibitors
Catechol-O-Methyltransferase Inhibitors
Antidepressants
Surgical Management
• Thalamotomy
– Improve tremor and rigidity
• Pallidotomy
– Improve tremor and rigidity, not for demented
people, they go in and burn stuff
• Deep brain stimulator
– Like a pacemaker thing in your brain
– The first two are permanent, once it’s done it’s
done. The DBS can be turned on or off or moved
from place to place
Nursing Diagnoses
•
•
•
•
•
•
Risk for falls
Self-care deficit
Chronic confusion
Impaired physical mobility
Impaired verbal communication
Risk for imbalanced nutrition: Less than
body requirements
Huntington’s Disease
• Chronic, progressive, hereditary disease
of the nervous system that results in
progressive involuntary choreiform (dance
like) movement and dementia
• It is transmitted as an autosomal dominant
genetic disorder, & each child of a parent
with the disease has a 50% risk of
inheriting the disorder (very genetic!! But
you usually don’t know you have it until
you have children)
Pathophysiology
• Premature death of cells in the striatum of the
basal ganglia
• Researchers believe glutamine abnormally collects
in the cell nucleus causing cell death
• Onset between the ages of 35-45
• Slowly progressive disease
• Patients usually become emaciated & exhausted
– Because they are dancing around all day long
uncontrollably!
• Death after 10 – 20 yrs
Clinical Manifestations
•
•
•
•
•
•
•
•
Abnormal involuntary movements (chorea)
Increasing intellectual decline
Emotional disturbance
Constant writhing, twisting, uncontrollable
movement of the body
Facial tics & grimaces
Slurred, hesitant, explosive, unintelligible speech
Chewing/swallowing difficulty
As this gets worse, all these things get worse!
Clinical Manifestations
• Disorganized gait – ambulation becomes
impossible
• Incontinence of bowel and bladder
• Affected cognitive function
• Emotional changes
– Nervous
– Impatient
– Suicidal depression
– Irritable
– Uncontrollable fits
– Apathy/Euphoria
Assessment & Diagnostic Findings
• Clinical presentation
• Positive family history
• Genetic marker
Medical Management
• Pharmacological
– Antipsychotics, antidepressants
• Nursing
– Maintain safety
– Treat physical symptoms
– Provide physical & emotional support
– Provide nutritional support
Alzheimer’s Disease
• Chronic, progressive, & degenerative brain
disorder that is accompanied by profound
effects on memory, cognition, & ability for
self-care
• One of the most feared disorders of
modern times due to its catastrophic
consequences for the patient & family
– Usually the pt doesn’t know they’ve lost their
mind, it’s the people left to take care of them
that suffer the most
10 Warning Signs
•
•
•
•
•
•
•
•
•
•
1. Memory loss
2. Difficulty performing familiar tasks
3. Problems with language
4. Disorientation to time and place
5. Poor or decreased judgment
6. Problems with abstract thinking
7. Misplacing things
8. Changes in mood or behavior
9. Changes in personality
10. Loss of initiative
Alzheimer’s Disease
symptoms
Normal age-related
memory changes
Forgets entire
experience
Forgets part of an
experience
Rarely remembers later
Often remembers later
Gradually unable to
follow written/spoken
direction
Usually able to follow
written/spoken direction
Gradually unable to use
notes as reminders
Usually able to use
notes as reminders
Gradually unable to care
for self
Usually able to care for
self
Stages of Alzheimer’s
• Stage 1
– Duration: 1 – 3 years
– Short-term memory loss
– Decreased attention span
– Subtle personality changes
• Only noticed by family members who were familiar
with their personality before hand
– Mild cognitive deficits
– Difficulty with depth perception
Stages of Alzheimer’s
• Stage 2
– Duration: 2 – 10 years
– Obvious memory loss
– Confusion
– Wandering behavior
– “Sundowning”
• Sun goes down and they get crazier
– Irritability and agitation
– Decreased spatial orientation
– Impaired motor skills
– Impaired judgment
Stages of Alzheimer’s
• Stage 3
– Duration: 8 – 10 years
– Absent cognitive abilities
– Disoriented to time and place
– Severely altered communication skills
– Impaired or absent motor skills
– Bowel and bladder incontinence
– Inability to recognize family & friends
– Disturbed sleep patterns/increased sleep time
Diagnostic & Assessment Findings
• Exclude all other diagnoses
– Get blood work to make sure you’re not depressed,
have had alcohol/drug abuse, drug toxicities, B12
and folate deficiency, thyroid problems, glucose
problems, etc.
• CT/MRI
– Smaller brain (atrophy), enlarged ventricles
• MMSE
– Mini Mental Status Exam. Shows degree of cognitive
impairment using a series of questions
• Neuropsychologic testing
– Diagnostic testing done by a neuropsychologist. Kind
of the same thing as above, done to gain a baseline
and to compare over time. Takes 4 or 5 hours to do
Medical Management
• Pharmacological
–
–
–
–
Cholinesterase inhibitors – Aricept
Memantine (Namenda)
Antipsychotics – haldol, risperdal, zyprexa
Antidepressants – prozac, zoloft
• Especially in the beginning when they’ve been diagnosed and
their brain is still there. They might get sad when they know that
they will go crazy
• Nursing
–
–
–
–
Maintain safety
Help maintain functional ability
Help meet personal needs
Maintain dignity
• There is nothing that is going ot make the
alzheimers better, these are just used to slow
down the progression of the disease
Nursing Management
• Support cognitive function
• Promote physical safety
– Esp. at night (sundowning)
• Promote independence in
self-care
• Reduce anxiety &
agitation
• Improve communication
• Provide socialization
– Small amt of people at a
time, not the entire family,
they’ll get confused
• Promote adequate nutrition
– Keep it simple!
• Promote balanced activity &
rest
– Keep them busy during the
day so they’ll be pooped at
night and sleep, not wander
around
• Educate on home &
community based
assistance
Amyotrophic Lateral Sclerosis
Lou Gehrig’s Disease
• Definition – A disease of unknown cause in
which there is a loss of motor neurons in the
anterior horns of the spinal cord and the motor
nuclei of the lower brain stem.
• More men than women are affected
• Onset usually in the 5th or 6th decade of life
• The body deteriorates, but your brain is
completely aware of what’s going on…
ALS
• Characteristics
– Atrophy of hands, forearms, and legs
– Paralysis
– Death
• Typically occurs w/i 2 – 5 years of onset of
symptoms. Usually die b/c of respiratory
failure (paralyzation of the respiratory
muscles, suffocate to death)
Nursing Diagnoses
•
•
•
•
•
•
•
Risk for injury
Self-care deficit
Ineffective coping
Chronic confusion
Risk for impaired tissue integrity
Total urinary and bowel incontinence
Imbalanced nutrition: Less than body
requirements
Clinical Manifestations
• Fatigue while talking
• Tongue atrophy
– Weakness of soft palate
which impairs ability to
laugh, cough, or blow their
nose
• Dysphagia
– Difficulty swallowing
• Dysarthria
– Difficulty articulating your
words
• Nasal quality of speech
• Fasciculations of the face
– Like a quivering action of
the muscles, like a twitch.
Where the muscles
contract
• Weakness of the
hands and arms
• Spasticity
• Muscle atrophy
extending to flaccid
quadriplegia
• Eventual respiratory
muscle involvement
– This is usually how
they die
Assessment & Diagnostic Findings
• Based on S/S
• EMG
– Put needle in the muscle and they’re checking
for the muscle activity
• Muscle biopsy
– The only test you can get that will definitively
tell you if you have ALS or not. Go in and take
a piece of your muscle and look at it
• MRI
Management
• No known cure
• Utilize an interdisciplinary approach to maintain
optimum functioning
– Palliative care
• Riluzole – only drug approved for use in ALS
• Ongoing support and counseling are valuable
– Cause it’s rare and you’ll die quickly, hard to deal with
emotionally
• Treatment for spasticity
• End of life issues
Nursing Diagnoses
• Risk for injury
• Imbalanced nutrition, less than body
requirements
• Altered communication
• Risk for aspiration