Transcript Airgas template

Management of Patients
With Oncologic or
Degenerative
Neurologic Disorders
Copyright © 2008 Lippincott Williams & Wilkins.
1
Pathophysiologic Results of
Neurologic Oncologic Disorders
• Brain tumors
– Manifestations depend upon the tissues
infiltrated and compressed by the neoplasm
• Pathophysiologic events may include:
– Increased ICP
– Seizures
– Hydrocephalus
– Altered pituitary function (“master gland”)
2
Copyright © 2008 Lippincott Williams & Wilkins.
Oncologic Tumors
• Brain tumors
– Benign or malignant
– Classification is based upon location and histological
characteristics
• Types of primary tumors: table 57-12
– Gliomas (astrocytoma, GBM, oligodenrocytoma,
ependymoma, medulloblastoma)
– Meningiomas
– Acoustic neuromas (8th cranial nerve)
– Pituitary adenomas (hormonal effects)
• Metastatic tumors (lung, breast, GI, pancreas,
Copyright © 2008 Lippincott Williams & Wilkins.
3
Brain Tumors
• Symptoms are dependent upon the location and size
of the lesion and the compression of associated
structures
– Review localized symptoms, pg 2304)
• Manifestations:
– Localized or generalized neurologic symptoms
– Symptoms of increased ICP
– Headache (worse in AM)
– Vomiting (irritation of vagal centers of medulla)
– Visual disturbances (due to papilledema of optic nerve)
• Hormonal effects with pituitary adenoma
4
• Loss of hearing, tinnitus, and vertigo with acoustic
Copyright © 2008 Lippincott Williams & Wilkins.
Common Brain Tumor Sites
5
Copyright © 2008 Lippincott Williams & Wilkins.
Diagnostic Evaluation
• Neurologic examination
• CT scan
• MRI
• PET scan
• EEG
• Cytologic study of cerebral spinal fluid
• Biopsy
6
Copyright © 2008 Lippincott Williams & Wilkins.
MRI of the Brain Showing a
Low-Grade Glioma
7
Copyright © 2008 Lippincott Williams & Wilkins.
Medical Management
• Specific treatment depends upon the type,
location, and accessibility of the tumor
• Surgery
– Goal is removal of tumor without increasing neurological
symptoms or to relieve symptoms by decompression
– Craniotomy, transsphenoidal surgery, and stereotactic
procedures, laser therapy
• Radiation therapy
– External beam radiation
– Brachytherapy (implanted)
• Chemotherapy
8
Copyright © 2008 Lippincott Williams & Wilkins.
Stereotactic Image of Brain
Tumor and Computerized Image
of a Prescribed Radiation Dose
9
Copyright © 2008 Lippincott Williams & Wilkins.
Spinal Cord Tumors
• Classified according to their anatomic relation to the
spinal cord
– Intramedullary: within the cord
– Extramedullary, extradural: outside the dural membrane
• Manifestations include pain, weakness, and loss of
motor function, loss of reflexes, and loss of
sensation
• Treatment depends upon type of tumor and location
– Surgical removal
– Measures to relieve compression: dexamethasone
combined with radiation
Copyright © 2008 Lippincott Williams & Wilkins.
10
Nursing Process—Assessment of
the Patient With Cerebral
Metastases or Inoperable Brain
Tumors
• Baseline neurologic exam
• Patient function and coping; self-care ability;
movement; walking; speech; vision; and dealing
with seizures
• Symptoms that may distress the patient: pain,
respiration, bowel and bladder function, sleep, skin
integrity, fluid balance, and temperature regulation
• Nutritional status and dietary history
11
• Family coping and family process
Copyright © 2008 Lippincott Williams & Wilkins.
Nursing Process—Diagnosis of
Patient With Cerebral Metastases
or Inoperable Brain Tumors
• Self-care deficit
• Acute pain
• Impaired tissue perfusion, cerebral
• Imbalanced nutrition
• Anxiety
• Interrupted family processes
Copyright © 2008 Lippincott Williams & Wilkins.
12
Nursing Process—Planning the
Care of the Patient With Cerebral
Metastases or Inoperable Brain
Tumors
•
•
•
•
Maintain normal ICP
Maximize neurological functioning
Achieve pain and discomfort control
Be aware of long term implications with
respect to prognosis and functioning
13
Copyright © 2008 Lippincott Williams & Wilkins.
Interventions
• Encourage independence for as long as possible
• Implement measures to improve cognitive
function
– If behavioral issues, implement patient protection
measures
• Management of seizures
• Allow patient to participate in decision making
• Provide referral to counselor, social worker, home
health care, and support groups as needed
• Provide referral for hospice care
14
Copyright © 2008 Lippincott Williams & Wilkins.
Improving Nutrition
• Provide oral hygiene
• Plan meals for times when the patient is
comfortable and well rested
• Implement measures to make mealtime as
pleasant as possible
• Offer preferred foods
• Provide dietary supplements
• Record daily weight
• Record dietary intake
15
Copyright © 2008 Lippincott Williams & Wilkins.
Degenerative Disorders
• Deterioration of normal cells or function
of the nervous system
16
Copyright © 2008 Lippincott Williams & Wilkins.
Parkinson’s Disease
• Progressive neurological movement disease
– Idiopathic or secondary
– Onset usually 5th - 6th decade of life; men>women
• Associated with decreased levels of dopamine due to
destruction of cells in the substantia nigra in the basal
ganglia; this effects the neurotransmission of impulses
• Manifestations - occur gradually
– * Tremor (“pill rolling”), *rigidity, *bradykinesia, postural
instability (esp. shuffling gait), depression and other psychiatric
changes, dementia, autonomic symptoms, and sleep
disturbances
• Insidious onset
17
Copyright © 2008 Lippincott Williams & Wilkins.
Pathophysiology of Parkinson’s
Disease
<<Key problem
18
Copyright © 2008 Lippincott Williams & Wilkins.
Parkinson’s Disease - Medical
Mgmt
Treatment is directed at controlling symptoms and
maintaining functional independence’
– Meds work by increasing dopaminergic activity and
reducing excessive influence of cholingergic neurons
• Antiparkinsonian
– Levodopa (converted to dopamine in the basal ganglia)
• Administered with carbidopa (maximizes benefits of levodopa)
• Patients develop dyskinesic response to drug over time
• Regimen loses effectiveness
19
Copyright © 2008 Lippincott Williams & Wilkins.
Parkinson’s Disease Medical
Mgmt
• Anticholinergic therapy
– Benztropine (Cogentin)
• Control tremor and rigidity
• Side effects; poor choice for elderly
• Antiviral therapy
– Amantadine (Symmetrel)
• Reduce rigidity, tremor, bradykinesia, postural
changes
• Side effects
20
Copyright © 2008 Lippincott Williams & Wilkins.
Parkinson’s Disease Medical
Management
• Dopamine agonists
– Bromocriptine (Parlodel)and pergolide (Permax)
– Ropinirole (Requip) and pramipexole (Mirapex) newer
• May be used to delay levodopa/carbidopa therapy or added to
that regimen once it begins to lose effectiveness
• Side effects
• Monoamine oxidase inhibitors
• COMT inhibitors
• Antidepressants
21
Copyright © 2008 Lippincott Williams & Wilkins.
Parkinson’s Disease - Nursing
Care
• Improve mobility
• Enhance self-care ability and
independence in activities of daily living
• Support coping
• Improving bowel elimination
• Optimizing nutrition
• Enhance swallowing
22
Copyright © 2008 Lippincott Williams & Wilkins.
Huntington’s Disease
• A chronic progressive hereditary disease that
results in choreiform movement and dementia
• Transmitted as an autosomal dominant trait (50%)
• Pathology involves the loss of cells in the striatum
of the basal ganglia (involved in movement
control), cortex (memory, thinking, perception)and
cerebellum (voluntary muscle activity
• Onset 35-45
• Death in 10-20 years r/t physical and mental
decline; incurable
Copyright © 2008 Lippincott Williams & Wilkins.
23
Alzheimer's Disease
• Also called senile dementia, Alzheimer’s disease is
the most common cause of dementia; usually >age
60
– Amyloid plaques and tangles develop in the brain;
gradual loss of connections between neurons
• A chronic, progressive, degenerative brain disorder
that destroys memory and thinking skills, and
eventually leads to the inability to carry out simple
tasks
• Affects 4.5 million people in the U.S.
24
Copyright © 2008 Lippincott Williams & Wilkins.
Alzheimer's Disease
• Manifestations are insidious; often mild memory
impairment
– Mild may include memory problems, poor judgement,
mood and personality changes
– Moderate may include worsening memory loss, difficulty
recognizing family and friends, inability to learn new
things, carry out multistep activities; may have delusions,
paranoia, impulsiveness
– Severe involves inability to communicate, complete
dependence on others for care
Copyright © 2008 Lippincott Williams & Wilkins.
25
Alzheimer’s Disease
• Management
– Medications
•
•
•
•
Donepezil, rivastigmine, galantamine, memantine
Antidepressants for associated depression
Halperidol, other neuroleptics for psychotic symptoms
Symptom management only
– Managing behavioral problems
26
Copyright © 2008 Lippincott Williams & Wilkins.
Alzheimer’s Disease
• Nursing Management
– Promote function and independence as long as possible
– Support cognitive function
• Calm, predictable environment
• Active participation and communication
–
–
–
–
–
–
–
Promote physical safety
Promote independence in self-care activities
Reduce agitation and anxiety
Improve communication
Provide for socialization and intimacy needs
Promote adequate nutrition
Community-based care
27
Copyright © 2008 Lippincott Williams & Wilkins.
Amyotrophic Lateral Sclerosis
(ALS)
• “Lou Gehrig’s disease”; onset 5th or 6th decades
• Loss of motor neurons in the anterior horn of
the spinal cord and loss of motor nuclei in the
brain stem cause progressive weakness and
atrophy of the muscles of the extremities and
trunk; weakness of the bulbar muscles impairs
swallowing and talking; and respiratory function is
also impaired
28
Copyright © 2008 Lippincott Williams & Wilkins.
Amyotrophic Lateral Sclerosis
(ALS)
• Clinical Manifestations
– Fatigue, progressive weakness, cramps, fasciculations,
incoordination, spasticity
– May begin, but usually progresses, to weakness in
muscles supplied by cranial nerves: difficulty talking,
swallowing, and ultimately breathing occurs
• Prognosis is based on area of CNS involvement
and speed of disease progression
• Death usually results from respiratory failure,
infection, or aspiration
• Diagnosis based on signs and symptoms; MRI may
29
assist
Copyright © 2008 Lippincott Williams & Wilkins.
Amytrophic Lateral Sclerosis
• Nursing care will be focused on
– Prevention of aspiration
– Facilitate communication
– Assist with endurance exercises
– Decrease pain secondary to muscle weakness
– Decreasing risk of injury related to falls
– Providing diversional activity a
– Helping the patient and family manage the
disease process, including grieving
30
Copyright © 2008 Lippincott Williams & Wilkins.