Transcript Neurology - Porterville College

Neurology
Alzheimer's Disease
(and other things we need to cover)
Alzheimer’s Disease
AKA
• AD
• Primary degenerative
dementia
• Senile dementia
• Organic Brain Syndrome
• Old timers disease
Pathophysiology
• Dementia
– Characterized by an
uneven, downward decline
in mental function
Pathophysiology
Alzheimer’s
• Progressive
• Irreversible
• Degenerative neurologic
disease
• Begins insidiously
• Characterized by
– Gradual losses of cognitive
function
– Disturbances in behavior &
affect
Pathophysiology
• Physical changes o the
cerebral cortex are visible
under a microscope
– Neurofibriallary tangles
– Neuritic plaque
– Decrease in brain size
Pathophysiology
• First affected
– Cells that use Acetylcholine
– Left side
– Parietal & temporal lobes
Etiology
• Familial tendencies
• Risk factor
– Age
• Men vs. women?
– Equal
Clinical Manifestations
• Slowly progressive
• Subtle
• Age
– 85+
Clinical Manifestations
• 3 categories of Changes
characteristic of dementia
–
– Cognitive
– Functional
– Behavioral
Clinical Manifestations
Stage 1- Early
• Cognitive
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Forgetful
Subtle mild memory loss
i attention span
Recent memory  remote
memory
Clinical Manifestations
• Stage 1 – early
• Functional
– Small difficulty in work (able
to hide it)
– Mild anomia (cannot name
objects)
– No motor deficits
Clinical Manifestations
Stage 1 – early
• Behavioral
– Depression
– Little interest in immediate
surroundings
– Lack of spontaneity
– Social behavior intact
– Hide cognitive deficit
Stage 2 – Middle
• Cognitive
– Obvious short term
memory lapses
– Disoriented to time
– Impaired judgment
– Frequent loss of objects
– Repeat the same story
– Ability to think abstractly
disappears
Stage 2 – middle
• Functional
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Hesitancy in verbal responses
Confabulation
Gets lost in familiar places
i ability to handle money,
use phone
Stage 2 – middle
• Behavior
– May try to hide memory
problems
– Impulsive behavior
– Hyperactive
Stage 3 – Late
• Cognitive
– Disintegration of personality
– Disorientation to person,
place and time
– Confused
– Agitation
– Irritability
– Paranoid delusions
Stage 3 – Late
• Functional
– May forget to use objects
correctly
– Dysarthria
Stage 3 – late
• Behavioral
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Wandering
Restlessness
Pacing
Agitation
Disengages from activities &
relationships
– Combative
Stage 3 – late
• Behavioral
– Sundowning
• Confused & restless after
dark
• Want to go home
• Less coping ability
Stage 4 – End Stage
• Cognitive
– Terminal stage
– Severe physical and mental
deterioration
– No recognition of family or
self
Stage 4 – End stage
• Functional
– Need total care for ADL’s
– Incontinent
– Loss of ability to
communicate
– Loss of all voluntary activity
– Swallowing problems
Review: Stage 1 (mild)
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Confusion and memory loss
Disorientation to time and place
Difficulty in performing routine tasks
Change in personality and judgment
Review: Stage 2 (moderate)
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Difficulty performing ADL’s
Anxiety
Suspiciousness
Agitation
Wandering
Pacing
Sleep disturbances
Difficulty recognizing family members
Review: Stage 3 (Severe)
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Loss of speech
Loss of appetite
Weight loss
Loss of B&B control
Total dependence on caregiver
Assessment & Diagnosis
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Hx & PE
Neuro tests
Autopsy
MRI
– Apparent changes
• Cognitive assessment
scale
• Functional dementia
scale
• Mini-Mental Status Exam
– Disorientation
– Cognitive impairment
Medical Management
• Exercise
– i anxiety & restlessness
– PT
• Diet
– Well balanced
– Hydration
Medical Management
Rx
• Cognex (tacrine Hydrochloride)
– Enhances acetylcholine
uptake in the brain
– S/E/
• Liver toxicity
• Aricept (donepezil)
– cholinesterase inhibitor
– Improves mental
function
– by increasing the
amount acetylcholine
Nursing Management
Priority Nrs Dx.
• Risk of injury
• Anxiety
• Communication
• ADL
• Alt. Nutrition
Nursing Management
• Sundowning
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DC all non-essential meds
Check for pain
Light on
Exercise daily
No caffeine
Anti-depressants
– Having the patient sleep in a
chair is better than no sleep
at all
Nursing Management
Supporting Cognitive function
• Calm, predictable environment
• Limit environmental stimuli
• Regular routine
• Quiet pleasant manner of
speaking
• Clear & simple explanations
Nursing Management
Supporting cognitive
function
• Memory aids
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Colanders
Pictures
Stop signs
Clocks
Instruction signs/notes
Pill organizer
Nursing Management
Promoting Physical safety
• Move around freely
• Remove hazards
• Nightlights
• Medications
• Food
• Smoking with supervision
• Restraints?
– NO!
Nursing Management
Promoting Physical safety
• Secure doors
• Wear ID
• Care at night
• Shoes
• A client has been recently admitted with a medical diagnosis
of dementia, Alzheimer’s type. When obtaining an
assessment, the nurse should remember for safety purposes
to ascertain what crucial information?
A.
B.
C.
D.
Sleep patterns and behavior
Skin turgor
The degree of memory impairment
The level of distractibility
Nursing Management
Reducing anxiety & agitation
• Uncluttered
• Familiar
• Low stimuli
• Calm & hurried care
• Music
• Stroking
• Rocking
• Distraction
Nursing Management
Reducing anxiety
• Validation therapy
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Enter their reality
Ask questions
Feelings
Distract
• Reality orientation
• Structure activities
• Avoid triggers
Nursing Management
Improving communication
• Unhurried
• i noise
• i distractions
• Clear & easy
• List
• Simple written
• Non-verbal
Nursing Management
Promoting independence
• Highest level of function
• Clothing
• Simple steps
• Personal dignity
• Choices
• Dangerous activities
Nursing Management
Promoting Socialization &
intimacy
• Visits Good
– Short
– Non-stress
– 1 or 2 at a time
• Simple activities
• Walking
Nursing Management
• Exercise
• Pet therapy
• Intimacy????
Nursing Management
Adequate nutrition
• Calm & simple
• Familiar foods
• Look appetizing
• Taste good
• 1 food at a time
• Small pieces
Nursing Management
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Finger foods
Food on the run
Watch hot food
Bibs?
Dental care
Nursing Management
Balance activity and Rest
• Wandering
• Assess sleep pattern
• Day time
– Exercise
– Regular patterns
– Limit long naps
Nursing Management
• Sleep aid
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Warm milk
Music
Back rub
Warm bath
Tea
Complications
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Malnutrition
Dehydration
Pneumonia
Pain
– Grimacing
– Restlessness
– Flexed position
Small Group Questions
• Damage to the brain in a patient with
Alzheimer’s Disease occurs where?
• What memory is lost first in a patient with
Alzheimer’s disease?
• Which neurotransmitter is associated with
memory
• Given three nursing intervention for a patient
with Alzheimer’s who is losing weight?
• A patient is confused and wandering. What intervention will
best maintain safety?
• What about night time wandering?
• A patient with Alzheimer’s occasionally she screams and
moans and annoys the other patients by repeating the same
word over and over. The best approach for a solution to this
behavior is for the nurses to do what?
• What medications are being used to treat AD?
• What activities are good for a patient who is
confused or has short attention span?
• What are the priority nursing diagnosis for
someone with AD?
• Give an example of confabulation
• What is the biggest risk factor for AD?
• When are AD patient most agitated?
Strategies to Minimize or Prevent
Sundowning
• Make sure sundowning is not the result of physical illness or medication.
• Caregivers need to be flexible in their approach and in their
expectations.
• Avoid caffeine drinks in the afternoon and evening.
• Have non-glare lighting.
• Be soothing and try to be undemanding. Try to make the person with
Alzheimer's feel safe and secure.
• Make sure the person's physical needs are met, i.e. that they
are not hungry, thirsty, or constipated.
• Avoid too many naps during the day.
• Soothing music may help relax them.
• Provide stimulating activities in the day without exhausting
the person.
• Remember that a person with Alzheimer's does not have
control over their behavior
A 93 year-old female with a history of Alzheimer’s Disease
gets admitted to an Alzheimer’s unit. The patient has
exhibited signs of increased confusion and limited
stability with gait. Moreover, the patient is refusing to use
a w/c. Which of the following is the most appropriate
course of action for the nurse?
A. Recommend the patient remain in her room at all times.
B. Recommend family members bring pictures to the
patient’s room.
C. Recommend a speech therapy consult to the doctor.
D. Recommend the patient attempt to walk pushing the
w/c for safety.
• Fill in the blanks of the statement with the
appropriate terms regarding the
pathophysiology of a patient who has
Alzheimer's disease: Researchers have
identified two microscopic changes, ____ &
____, that occur in the brain of a patient with
Alzheimer’s disease. These changes result in
cortical atrophy.
A. Neuritic plaques
B. Neurofibrillay tangles
C. Nerve demyelination
D. Sclerotic plaques
E. Dysplasia
Cerebral Palsy
Pathophysiology
• Non progressive
• D/T cerebral anoxia
during birth
• Results in CNS damage
• No Cure!
Poliomyelitis
Pathophysiology
• Virus
• Mode of transmission
– Fecal-oral
Poliomyelitis
Clinical Manifestations
• Cold-like symptoms
• Pain & stiffness
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Back
Neck
Legs
Bulbar paralysis
Poliomyelitis
Prevention
• VACCINE
– IPV
• Inactive Polio Vaccine
• Killed virus
• Salk vaccine
– OPV
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•
•
•
Oral polio Vaccine
Live vaccine
Can cause polio in some
Not used in USA
Poliomyelitis
Vaccination schedule
• 2 months
• 4 months
• 6-18 months
• Booster 4-6 years
The nurse is preparing to discharge a client with
a long history of polio. The nurse should tell
the client that:
A. Taking a hot bath will decrease stiffness and
spasticity.
B. A schedule of strenuous exercise will
improve muscle strength.
C. Rest periods should be scheduled
throughout the day.
D. Visual disturbances can be corrected with
prescription glasses.
Neurosyphilis
Pathophysiology
• Bacteria
• Mode of transmission
– STD
•
•
•
•
Mucus membrane 
Systemic 
Lymph 
Brain & Spinal cord
Neurosyphilis
• Tabes dorsalis =
– posterior nerve root
involvement
– Paralysis
• Seizures
• H/A
• Hemiparesis
Neurosyphilis
Treatment
• Antibiotics
• Both partners
• Infants
Varicella / Herpes Zoster
Pathophysiology
• Virus
• Mode of transmission
– Airborne
– Contact
• Incubation period
– 2 weeks
Varicella / Herpes Zoster
Pathophysiology
• Exposure 
• Prodromal stage
– General malaise
– No rash
– Contagious!
Varicella / Herpes Zoster
• Rash stage
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CHICKEN POX’s
Vesicular & pustular
Spread rapidly
New lesions for 2-3 days
Varicella / Herpes Zoster
• Scab stage
– Lesion begin to dry
– No new lesion
– lesions crusted
• Not contagious
Varicella / Herpes Zoster
• Dormant stage
– Virus retreats
– Dormant
– Dorsal horn of the spinal
cord
Varicella / Herpes Zoster
• Reactivated
– Later!!!!
• Stress
• Decreased immune
system
– Reactivated
– Along peripheral nerve
– Shingles
Varicella / Herpes Zoster
S&S of shingles
• Tingling
• Itching
• Pain
• Rash
– Red bumps
– Blisters
Varicella / Herpes Zoster
• Prevention
– Varicella vaccine
– (85% effective)
• Treatment
– Self-limiting
– Anti-viral meds
– NO aspirin 
• Reye syndrome
• Liver failure
Question
•
An adult who has never had chicken pox’s or
the varicella vaccine and is exposed to a
child with chicken pox, is at risk of
developing what?
A. Chicken pox’s
B. Shingles
C. Nothing, varicella only affects children
Question
• An adult who has never had chicken pox’s or
the varicella vaccine is exposed to an adult
with shingles. What is the adult at risk of
developing?
A. Chicken pox’s
B. Shingles
C. Syphilis
Question
• An adult who had chicken pox’s as a child is
exposed to an adult with shingles. What is the
adult at risk of developing?
A. Chicken pox’s
B. Shingles
C. Nothing
Question
•
A.
B.
C.
D.
E.
What must happen before a person can
develop shingles?
They must be a door mat
They must go to sleep
They must have cancer
They must have chicken pox’s
They must have spinal cord injury
Question
•
A.
B.
C.
D.
E.
Which of the following can lead to an
outbreak in shingles (of a patient with
dormant herpes Zoster)
Stress
Cancer
Immunosuppressant medication
Exposure to a person with chicken pox’s
Exposure to a person with shingles