Transcript Problems of the Central Nervous System

Problems of the
Central Nervous System
EPILEPSY, SPINA BIFIDA,
CEREBRAL PALSY
2009
SEIZURE DEFINED
• Episodes of abnormal sudden, excessive,
uncontrolled electrical discharge of neurons
within the brain
• May result in alteration in consciousness,
motor or sensory ability and/or behavior
EPILEPSY
• Chronic disorder
• Characterized by recurrent unprovoked
seizure activity
CAUSE OF EPILEPSY
• abnormal electrical neuronal activity
• Imbalance of neurotransmitters: Gamma
aminobutyric acid (GABA)
CAUSE OF SEIZURES
• Inherited
• Cause is unknown (idiopathic)
Can follow:
• Birth trauma
• Asphyxia during birth
• Head injuries
• Infectious disease
• Toxicity (carbon monoxide and lead poisoning)
• Fever
• Drug/alcohol intoxication
• Brain tumors
INTERNATIONAL CLASSIFICATION OF SEIZURES
• Classified by the part of the brain involved
– PARTIAL SEIZURES beginning in one part of one cerebral
hemisphere
• Complex partial seizures
• Simple partial seizures
– GENERALIZED SEIZURES involving both cerebral
hemispheres
– UNCLASSIFIED SEIZURES:
• Unclassified
• Idiopathic
PARTIAL SEIZURES
• Simple partial seizures
• Complex partial seizures
PARTIAL SEIZURES
• SIMPLE PARTIAL SEIZURES:
– Unilateral movement of extremity
– Unusual sensations
– Autonomic or psychic symptoms (heart rate,
flushing, epigastric discomfort)
– May experience unusual or unpleasant sights,
sounds, odors, tastes (aura) occurring before
seizure
– No loss of consciousness
COMPLEX PARTIAL
– Automatism: Person remains motionless or moves
automatically, but inappropriately for time and
place (eg: lip smacking, patting, picking at clothes)
– May experience excessive emotions of fear, anger,
elation, or irritability
– No memory of episode, loss of consciousness,
black out 1-3 min
GENERALIZED SEIZURES (previously GRAND
MAL)
• TONIC-CLONIC SEIZURE
– Lasts 2-5 min
– Starts with tonic movements: stiffening or rigidity of the
muscles of arms and legs
– Loss of consciousness
– Clonic movements follow: rhythmic jerking of all
extremities
– May bite tongue, incontinent of urine/feces
– Followed by an hour of fatigue, confusion, lethargy
GENERALIZED SEIZURES CONTINUED
• Tonic seizures:
– Abrupt increase in muscle tone
– Loss of consciousness
– Loss of autonomic signs for 30 sec to several minutes
• Clonic seizure:
– Lasts several minutes
– Muscle contraction and relaxation
GENERALIZED SEIZURES CONTINUED
• Absence seizure
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Common in children
Runs in families
Brief (seconds) loss of consciousness
Blank starring, returning to normal
May occur frequently throughout day
• Myoclonic seizure:
– Brief jerking/stiffening extremities
– Singly or in groups
– Lasts few seconds
GENERALIZED SEIZURES CONTINUED
• Atonic(akinetic)seizure
– Sudden loss of muscle tone for a few seconds,
may fall
– Followed by POSTICTAL(after seizure) confusion
POST-ICTAL STATE
• POST-ICTAL STATE: after seizure
Pt is confused and hard to arouse, may sleep
for hours
ASSESSMENT AND DIAGNOSTIC TESTS
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History
Identify causes
MRI
EEG
SPECT (single photon emission computed
tomography) – helps identify zone giving rise
to seizures, can then be removed surgically
TREATMENT
• Remove or treat cause
• Surgically remove/excise the part of the brain
that is causing the problem as long as it
doesn’t produce neurologic deficits
– Pt is alert
• Generator may be implanted under the
clavicle: helps control the seizure
MEDICATIONS:
antiepileptics (AED’s)
• Unknown why they work
• Control seizures, do not cure
• Starts with one med, dosage gradually increased looking for
SE, may add another drug
• Therapeutic blood levels: Blood levels checked, absorption
varies among patients
• Dosage changed with illness, weight changes, stress
• Sudden withdrawal avoided
• Lots of drug/drug interactions and drug/food interactions
SIDE EFFECTS OF DRUGS
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Allergic reaction (skin)
Acute toxicity (seen initially)
Chronic toxicity (seen later in therapy)
REACTIONS seen in an organ
Common SE of Dilantin: gingival hyperplasia
(swollen and tender gums)
ASSESSMENT DURING SEIZURE
• Assess for preseizure behavior, aura, loss of
consciousness
• Assess seizure activity
• Record the time the activity began
• Assess for fecal or urinary incontinence
• Assess for post seizure behavior (memory loss,
loss of consciousness, lethargy)
RECORD SEIZURE ACTIVITY
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Include onset time
Include focus of seizure (part of body involved)
Identify duration of seizure (time)
Identify change in respirations
Define progression of movement through body
Identify changes in neurological status
Describe post-ictal activity (duration, status,
behavior)
IMPLEMENTATION
• Gently lower the standing or sitting patient to the
floor (supine)
• Turn the head to the side, hyperextend neck and pull
jaw slightly forward
• Maintain patent airway
• Have oxygen and suction available whenever a
patient indicates they have a history of seizures!!!
• PLACE NOTHING IN THE MOUTH!
IMPLEMENTATION CONTINUED
• Do not restrain the patient
• Remove dangerous objects the might injure
the patient
• Loosen tight or restrictive clothing
• Record seizure activity
TEACHING
• Wear Medic Alert
• Avoid stimulant drugs (caffeine) may cause a seizure
to break through the anticonvulsant medication
• Avoid alcohol – can cause overdose of medications
• Teach family/patient triggers to seizures:
hypoglycemia, fatigue, exhaustion, hormonal
changes, illness, stress, alcohol, caffeine,
constipation, hyperventilation, excessive activity
TEACHING CONTINUED
• High fiber diet/high fluid diet to prevent constipation
caused by anticonvulsant meds
• Adequate rest, stress reduction, good diet
• Anticonvulsant meds cause gingival hyperplasia:
need good dental care
• Provide name of local Epilepsy Foundation
• Assist in dealing with feelings
RESTRICTIONS until seizure free for 3
months to 1 year
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No driving motor vehicles
No operating heavy machinery
No working in potentially dangerous situations
No swimming, no water sports
Possibly no tub bathing
LENGTH OF RESTRICTION DEPENDS UPON
STATE REGULATIONS
MEDICATIONS
Dilantin (phenytoin)
Therapeutic drug level 5-20 ug/dl
• Cannot be withdrawn suddenly
• Watch for toxicity (nystagmus, ataxia, dysarthria,
encephalopathy)
• Do not combine with warfarin (Coumadin)
SIDE EFFECTS:
• Lethargy, abnormal movements, Gingival hyperplasia, mental
confusion, cognitive changes
MEDICATIONS FOR STATUS
EPILEPTICUS
Fosphenytoin (Cerebyx)
Diazepam (Valium); give slowly, drug of choice
for status epilepticus, have ventilatory support
available
Lorazepam (Ativan)
Given IV during status epilepticus
MEDICATIONS
• Ethosuximide (Zarontin): N & V, gastric
distress, gradually withdraw
• Carbamazepine (Tegretol): expensive, watch
effects on heart and lungs
• Valproate (Depakene): effects liver, causes
tremors, alopecia
• Galbapentin (Neurotonin): dizziness,
somnolence, wgt gain
MEDICATIONS
Clonazepam (Klonopin): drowsiness, palpitations
Felbamate (Felbatol): cognitive impairments
Lamotrigine (Lamictal): tremor
Levetiracetam (Keppra): somnolence
Oxacarbazepine (Trileptal): tremor, loss of
coordination
MEDICATIONS
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Phenobarbitol (Luminal): sedation
Primidone (mysoline): lethargy, impotence
Tiagabine (Gabitril): dizziness, buckling knees
Topiramate (Topamax): fatigue, anorexia, depression
Zonisamide (Zonegran): somnolence, agitation
STATUS EPILEPTICUS
• Series of generalized seizures tht occur
without full recovery of consciousness
between attacks
• Also includes continuous electrical seizures
lasting at least 30 minutes even without
impairment of consciousness
RISKS OF STATUS EPILEPTICUS
• Respiratory arrest at height of each seizure
leading to hypoxia which can lead to brainb
damage
FACTORS THAT TRIGGER STATUS
EPILEPTICUS
• Withdrawal of seizure meds
• Fever
• Concurrent infection
STATUS EPILEPTICUS
MEDICAL EMERGENCY
• cerbyx, Ativan, Valium IV
• Oxygen & Airway device/intubation inserted
between seizures
• Suction
• Hydration IV using glucose for hypoglycemia
(high metabolic demand during seizure)
TREATMENT FOR STATUS EPILEPTICUS
CONTINUED
• May have to anesthetize with short acting
barbiturate to stop seizure
• Serum levels of anti- seizure meds
• Cardiac/respiratory depression may be
lifethreatening
• Cerebral edema can occur
CEREBRAL PALSY
CEREBRAL PALSY
• DEFINED AS:
• A neurologic problem
• Characterized by impaired movement and
posture
• It involves a lack of motor control of voluntary
muscles
• Comes from a lesion in the brain that occurred
prenatally, at birth or postnatally
CAUSE OF CP
• PRIMARY CAUSE: ANOXIA
• SECONDARY CAUSE: INFECTION
CLINICAL MANIFESTATIONS
• Delayed gross motor development: universal
symptom
• Abnormal motor performance
• Alterations muscle tone: rigidity, stiffness
• Abnormal postures: scissoring
• Reflex abnormalities: persistance of primitive
infantile reflexes
ASSOCIATED DISABILITIES
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May have mental retardation
Common to have seizures
Attention deficit/hyperactivity
Sensory impairment
CLASSIFICATION
• Spastic: increased muscle tone
• Dyskinetic (athetoid): abnormal writhing
movements, drooling, dysarthria,
• Ataxic: difficulty with balance
• Mixed: athetoid and spastic
DIAGNOSIS
• Know growth and development
• Observe in newborn nursery
• Early recognition important
TREATMENT
• TEAM APPROACH
Goals:
• Establish locomotion, communication, selfhelp
• To gain optimum function
• To correct associated defects
• To provide educational opportunities
MOBILIZING DEVICES
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Braces
Ambulation devices
Scooter boards
Wheeled go carts
Strollers
w/c
SURGERY
• Orthopedic
• TAL (tendon achilles lengthening)
• release of tight wrist and hip muscles
NURSING CARE
1. FEEDING:
• Avoid semi-reclining
• Place in flexed position
• Gentle upward stroking of the neck
2. DIET: high calorie diet
3. MAINTAIN SKIN INTEGRITY
4. PROMOTE SELF-CONCEPT
NURSING CARE CONTINUED
5. PROMOTE KNOWLEDGE
6. USE THE PARENTS AS BEST RESOURCE
7. PROVIDE REST
8. PREVENT/TREAT RESPIRATORY INFECTIONS
9. DENTAL PROBLEMS
10. PROVIDE PARENTAL SUPPORT
SPINA BIFIDA
SPINA BIFIDA
DEFINED: incomplete fusion of one or more
vertebral laminae and defective development
of the spinal cord
ETIOLOGY:
• Environmental
• Genetic
• Vitamin deficiency
CATEGORIES
• MENINGOMYELOCELE OR
MYELOMENINGOCELE
• MENINGOCELE
• SPINA BIFIDA OCCULTA
MENINGOMYELOCELE (MMC)
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Most common
Involves the spinal cord
Have soft rounded protrusion
Sac containing meninges, portions of spinal
cord and nerve roots and CSF
• Sac protrudes through defective vertebra
• MASS DOES NOT TRANSILLUMINATE
MMC CONTINUED
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DEGREE OF NEUROLOGIC DYSFUNCTION
Flaccid lower extremities
Partial paralysis
Bowel and bladder incontinence
Deformities
MENINGOCELE
• Does not involve spinal cord
• Sac like cyst contains meninges with CSF, no
neural tissue
• MASS CAN BE TRANSILLUMINATED
• LACK OF PARALYSIS
SPINA BIFIDA OCCULTA
• Common, usually asymptomatic
• No external protrusion
• Failure of spinous processes to join in the L5
to S1 area
• Skin depression, dimple, birthmark, hair,
lipoma
• May have bowel/bladder sphincter control
prblems
MANAGEMENT
Multidisciplinary approach:
• Neurosurgeon
• Orthopedic surgeon
• GU
• Psychologist
• Educators
• Social workers
• Pediatric nurse clinician
NURSING MANAGEMENT
AT BIRTH
• Place under overhead warmer
• On abdomen
• Keep sac moist
SAC CARE
PREVENT RUPTURE, DRYING AND INFECTION OF
SAC
• Antibiotics IV
• Prone
• Skin care
• Soaks on sac (NSS, bacitracin, silver nitrate)
COMPLICATIONS
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MENINGITIS
NEUROLOGIC INVOLVEMENT
HEAT AND FLUID LOSS
LEAKAGE OF SPINAL FLUID
DEFORMITIES
SURGICAL REPAIR
• Neurosurgeon and plastic surgeon
• Excision of protrusion
POST-OP NURSING CARE
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Incubator/overhead warmer
Oxygen
Prone/some require head lowered
Plastic apron
NPO to clear fluids to full fluids
Daily head circumferences
Observe for hydrocephalus/meningitis/urinary
retention
CARE OF SITE AT HOME
• Wash the incision with peroxide and rinse
with water to remove crusts
• Observe for drainage and call MD
• Keep diaper below site
• After healed, tub baths
LONG TERM PROBLEMS
ORTHOPEDIC ABNORMALITIES
• Hip dislocations, club foot, scoliosis,
contractures in hips, knees, ankles
NURSING CARE:
• PROM, turning, check for reddened areas, pad
seats, cribs, soft toys, check toes, check braces
GENITOURINARY ABNORMALITIES
• Renal failure
• UTI
• Urinary retention
• Urinary reflux
TREATMENT: clean intermittent catherization
program
EXPERIMENTAL: artificial sphincters, bladder
pacemaker
NURSING CARE BLADDER
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Change diapers q 2 hrs
Wash bottom with antibacterial soap
No rubber pants
A&D and Desitin
Drugs which cause urinary retention
BOWEL MANAGEMENT
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Bowel control depends upon innervation
Regular toilet habits
Prevention of constipation and impaction
Diet high in fiber and high fluids
BOWEL PROGRAM: 2-3 yrs of age
Rectalaid enemas, cathartic (senekot)
DEVELOPMENTAL CONSIDERATIONS
• Toddler: can bear down by coughing or blowing up
balloons, bowel routine ritual
• Preschooler: asks why? Answer the truth
• “It’s because of the opening on your back when you
were born. You can’t go to the bathroom like other
people.”
• School age and Adolescent: do independently,
concern – privacy, peer rejection
SEXUALITY
• Males: erection and ejaculation possible, most
sterile from retrograde ejaculation
• Females: fertility well documented. 4-5% risk
of having a MMC child. SEX ED IMPORTANT.
PSYCOSOCIAL:
Multifaceted:
• Body image
• Sexuality
• Urinary problems
• Bowel problems