Transcript 192ace1c14bec10

Management of Patients with
Neurological disorders
Prepared
By:
Hanaa Farahat Ibrahim
Clinical Instructor in MubarakKhol Institute of Nursing
Under supervision of:
Prof. Dr. Magda Abd El Aziz
Prof. of Medical Surgical
Nursing Department
Faculty of Nursing
Ain-Shams University
2010
Cerebrovascular accident disorders
(Strokes)
“Stroke is the clinical term for acute loss of
perfusion to vascular supply of the brain,
resulting in ischemia and a corresponding loss
of neurologic function. Classified as either
hemorrhagic or ischemic, strokes typically
manifest with the sudden onset of focal
neurologic deficits, such as weakness, sensory
deficit, or difficulties with language.
Incidence of Stroke:
The World Health Organization
estimates that 15 million people suffer a
stroke worldwide each year, resulting in 5
million deaths and 5 million people
permanently disabled. While in the United
States approximately 795,000 strokes
occur each year (American Heart Association 2006).
Risk factors of Stroke
Nonmodifiable
Modifiable
•
•
•
•
•Life style habits
Age
Sex
Race
Heredity
( Alcohol intake – cigarette
smoking – obesity – high fatty
diet- drug abuse).
•Pathological
conditions
(Cardiac diseases- diabeteshypertension)
Etiology & Pathophysiology
To ensure optimal cerebral functions and
prevent neurologic deficits the blood flow must be
maintained at 750 to 1000 ml/min. (55 ml/100 g
brain tissue) or 20% of the cardiac output. If the
blood flow to the brain is totally interrupted,
neurologic metabolism is altered in 30 seconds,
metabolism stops in 2 minutes, and cellular
death occurs in 5 minutes.
Etiology & Pathophysiology CONT..
• Factors that affect the blood flow is
divided to :
• Extracranial factors
• Intracranial factors
• Atherosclerosis
Factors that affect the blood flow
Extracranial factors
Viscosity
Intracranial factors
Cardiac output
Metabolic factors
•High CO2
•Low O2 tension
•High Hydrogen ion
Atherosclerosis
Systemic blood
pressure
Mean BP fall below 70
mm Hg or raise above
160 mm Hg
Blood vessels
Increase intracranial
pressure
•Congenital anomalies
•Stroke , Neoplasm
Collateral circulation
•Inflammation, Trauma
•Hydrocephalus
Types of stroke
Ischemic stroke
Hemorrhagic stroke
Ischemic stroke
• Ischemic stroke or brain attack is a sudden loss of function resulting
from disruption of the blood supply to a part of the brain.
• Ischemic stroke are subdivided into five different types based on the
cause :
• Large artery thrombosis
• Small penetrating artery thrombosis
• Carcinogenic embolic stroke
• Cryptogenic strokes, which have unknown cause.
• Strokes from other causes, such as coagulopthies, migraine, and
spontaneous dissection of the carotid artery.
Patophysiology of ischemic stroke
Ischemia
Energy failure
Sign POD
Iron imbalance
Acidosis
Intracellular calcium increased
Glutamate
Depolarization
Cell membranes and protein break down formation
of free radical protein production
Cell
damage
Smeltzer & Bare 2009
Clinical manifestations of ischemic
stroke
• Numbness or weakness of the face, or leg,
especially on one side of the body
• Confusion or change on mental status
• Trouble speaking or understanding speech
• Visual disturbance
• Difficulty walking, dizziness, or loss of
balance or coordination.
• Sudden sever headache.
Neurologic deficits of stroke
Neurologic deficits
Manifestations
Visual field deficits
•Loss of halve of the visual field
•Unaware of persons or objects on
side of visual loss
•Neglect of one side of the body
Difficulty judging distance
•Loss of peripheral vision
•Difficulty seeing at night.
•Unaware of objects or the border
of the objects
•Diplopia
Double vision
Neurologic deficits of stroke Cont..
Neurologic deficits
Manifestations
Motor deficits
•Hemiparesis
•Weakness of the face, arm, and
leg on the same side due to lesion
on the opposite hemisphere
•Hemiplegia
•Paralysis of one side
•Ataxia
•Unsteady gait
•Dysarthria
•Difficulty in forming words
•Dysphagia
•Difficulty in swallowing
Neurologic deficits of stroke Cont..
Neurologic deficits
Manifestations
Sensory deficits
•Paresthesia
•Numbness and tingling of
extremity
Verbal deficits
•Expressive aphasia
•Unable to form words that are
understandable
•Receptive aphasia
•Unable to comprehend and
spoken words
•Global aphasia
•Combination of both receptive
and expressive aphasia
Neurologic deficits of stroke Cont..
Neurologic deficits
Manifestations
Cognitive deficits
•Short and long memory loss
•Decreased attention span
•Impaired ability to concentrate
•Poor abstract reasoning
•Altered judgment
Emotional deficits
•Loss of concept - Emotional labiality
•Decrease tolerance to stress
situation - depression - withdrawal
•Fear-hostility-anger-isolated
•Unable to form words that are
understandable
•Expressive aphasia
Hemorrhagic stroke
Intracerbral
hemorrhage
Subarchnoid
hemorrhage
Sites
Bleeding occurs most
commonly in the cerebral
lobes, basal ganglia,
thalamus, brain stem, and
cerebellum may lead to
rupture the wall of lateral
ventricle and cause
intraventriular hemorrhage
which is fetal.
Hemorrhage into the
subarchnoid space.
Causes
Caused by hypertension brain
tumor – trauma thrombolitic
drugs and rupture aneurysms.
Aneurysms, arteriovenous
malformations, trauma, and
hypertension.
Hemorrhagic stroke
Intracerbral
hemorrhage
Manifestations •Occur without prodromal
symptom and during activity.
•Severe headache – nausea vomiting.
•Weakness of one side – slurred
speech- hemiplegia – coma –
hyperthermia - death
Prognosis
•Is poor 70% of patient die after
stroke.
•The extent of the symptoms
various depending on the
amount and duration of the
bleeding.
Subarchnoid
hemorrhage
•The patient may exhibit
prodromal symptoms if the
dilatation of the artery make
compression on the brain
tissues. Headache – lethargy
– confusion – nausea –
vomiting – neck pain -feverparalysis – coma – death.
•Prognosis of patients is
guarded because many
patients experience another
bleed within 2 weeks of the
first occurrence.
Temporal development of
cerebrovascular accident
Transient Ischemic attacks (TIA)
• is characterized by brief episodes of neurologic manifestations,
which clear completely in less than 24 hr.
• It is though that the TIAS are a result of microemboli from
atherosclerotic plaques found in extracranial arteries that lead to
temporary cerebral ischemia.
• Patients should consider TIAs as a warning sign of progressing
cerebrovascular diseases. S & according to the site affected.
• If the carotid artery is involved the patient may report loss of vision –
transient hemiparesis – sudden inability to speak.
Diagnostic studies
• MRI or a CT scan
• Brain scan
• Lumbar puncture
• Carotid ultrasound
Diagnostic studies cont..
• Opthalmoscopy
• Cerebral angiography
• EEG
• Other lab tests as urine analysis – coagulation profile – CBC – serum
osmolarity – electrolyte – glucose – lipid profile creatinine and blood
urea nitrogen.
Managements of patient with stroke
I-Medical managements
- collaborative managements
- Drug used
- Rehabilitation care
II- Surgical managements
III- Nursing managements
I- Medical managements
• I- Collaborative care:
1-1 Prevention include:
1-1 stroke risk screening and health management for the
well individual, management of modifiable risk factors,
prevention of stroke for those with history of TIA, and
prevention of addiction and
• Health management focuses on healthy diet – weight
control- regular exercises – no smoking- limiting alcohol
consumption, routine health assessment, proper health
management for patient with hypertension – diabetes,
and cardiac problems.
1- Collaborative care cont…..
1-2 Drug therapy
• Low dose of aspirin is used prophylactically because of its antiplatelet
effects.
• Daily use of platelets aggregation inhibitors such as Ticlopidine (Ticlid)
as effective as aspirin in reducing the incidence of stroke.
1-3 Surgical therapy
Surgical for the patient with TIA
A- Carotid endarterectomy
B- Transluminal angioplasty
C- Extracranial – intracranial by pass
1-3 Surgical therapy
Surgical for the patient with TIA
A- Carotid endarterectomy( CEA)
The atheromatous lesion is removed from the carotid
artery to improve blood flow. CEA surgery is
associated with reduction of stroke and vascular
death.
B- Transluminal angioplasty
Is the insertion of a balloon to open a stenosed artery to
permit increase blood flow. Is used to treat patients
with stenosis in the carotid artery.
Surgical therapy cont..
C- Extracranial – intracranial bypass (EC-IC) bypass is
used for intracranial problems when obstruction
cannot be removed directly the procedure involves
anastomosing a branch for of an intracranial artery
to an intracranial artery beyond the area of
obstruction. Following the procedure these patients
are at high risk for stroke and require closed, long –
term assessment and management.
2- Acute care:
A- Goal for collaborative care during the acute
phase are:
• Preservation of life
• Prevention for further brain damage
• Reduction in the level of disability
B- To achieve this goals you should make initial assessment which
includes assessment of :
• ABC
• Altered level of consciousness by use Glasgow coma scaleweakness, numbness, and paralysis of one side of the body
• Speech or visual disturbance- unequal pupil
• Sever headache - vital signs ( increased or decreased heart rate
– respiratory distress- hypertension)
• Facial drooping on affected side
• Difficulty in swallowing
• Seizure
• Bladder or bowel incontinence
• Nausea and vomiting
C- Acute managements
1- Maintain air way patent by
• Ensure patent air way
• Remove denture
• Elevate head of bed 30 degrees if no symptoms
or shock.
2- Provide the patient with adequate oxygenation
through nasal cannual – mask or intubation and
mechanical ventilation
3- Establish IV access with normal saline to
maintain blood pressure
4- fluid and electrolyte replacement must be controlled
carefully
•
adequate fluid intake during acute care should be 1500
to 2000ml/day to promote perfusion to the brain and
prevent overehydration
• patient with ischemic stroke may be treated with
hypervolmic hemodilution and volume expansion with
crystalloids or colloids to decrease blood viscosity
• Monitor urine output for the patient with stroke to detect
urine retention caused by excessive secretion of
Antiduritic hormone
• IV solution with glucose and water are avoided to prevent
increase of intracranial pressure and brain edema
5- management of increased ICP includes:
•
•
•
•
•
•
•
•
Elevation of head
Maintain head and neck in alignment position
Avoidance of hip flexion
Avoidance of hyperthermia to limit cerebral tissue
metabolism and vasodilatation
Treatment of pain
Provide patient with laxative to prevent constipation
Mannitol and furosemide medication may be used to
reduce hypervolemia
Dexamethasone may be used for patient with brain
edema.
I-2- Drugs managements of stroke
• Thrombolitic therapy as tissue plasminogen activator
• Platelet inhibition/anticoagulant as heparin – warfarinaspirin and ticlid
• Other drugs:
• as acetaminophen to treat hyperthermia
• Anti seizure medication such as phenytoin
• Calcium channel blockers as nimodipine to decrease
effect of vasospasm and minimize tissues damage for
patient with subarchnoid hemorrhage.
Drug managements of stroke cont..
drugs
action
uses
Side effects and
nursing role
Tissue
plasminogen
activator (t-PA)
Produce localized
fibrinolysis by binding
to the fibrin in the
thrombi
•Is used to reestablish
blood flow and prevent
cell death for patient with
ischemic stroke
•Is effective if used
within 3 hours of the
stroke occurrence as
defined by the onset of
clinical manifestation
•Patients should be
screened carefully
before treatment
initiation . This include
blood test for
coagulation disorders –
GI bleeding and CT or
MRI to exclude
hemorrhagic stroke
-Cerebral
hemorrhage
-Frequent monitor
vital signs to assess
improvement or
deterioration related
to intracerebral
hemorrhage
-Control blood
pressure is critical
during treatment
and 24 hours
following treatment
-No anticoagulants
or antiplatelet drugs
are administered for
24 hours after t-PA
treatment.
II- Surgical therapy
Craniotomy surgery
• for evacuation of hematoma if the diameter
exceeds 3 cm and the Glasgow coma scale
score decreases for patient with intracerebellar
hemorrhage or aneurysm – induced
hematomas.
II- Surgical therapy CONT..
• Surgical clipping has been the traditional
method for treatment of brain aneurysms. This
method requires a neurosurgeon to perform a
craniotomy (removal of part of the skull) to
access the brain and blood vessels. The surgeon
blocks blood flow to the aneurysm by applying a
metal clip to its base, redirecting the blood flow
away from the aneurysm. Then the wound is
sealed again and closed.
• Endovascular Coil Therapy
Endovascular Coiling Therapy is a less
invasive treatment method that
produces better outcomes than
surgical clipping in certain patients
with cerebral aneurysm.
• A catheter (small tube) is inserted
into the patient’s femoral artery and
advanced through the body until the
aneurysm is accessed from the
inside.
• Small, soft platinum coils are inserted
through the catheter into the
aneurysm.
Endovascular Coil Therapy (cont.)
• The coils are packed into the aneurysm to block
the flow of blood into the aneurysm.
• By blocking the flow, the pressure on the
aneurysm is reduced.
• Over time, new tissue will grow at the opening of
the aneurysm and blood flow will be diverted
away from the aneurysm. The procedure is
performed in under the guidance of fluoroscopic
X-rays. The fluoroscopy allows the physician to
visualize the vasculature and properly place the
coils.
• For patients with subarchnoid and intracerebral
hemorrhage can involve bleeding into the ventricle of the
brain.
• Ventriculostomy and drainage relive hydrocephalus,
which further damages brain tissue from increased
intracranial pressure
Rehabilitation care
Rehabilitation team
Nurse
Physician
Pharmacist
Occupational
therapy
Physical
therapy
Speech
pathologist
Social
worker
Patient
and
family
Vocational
counselor
Recreation
al therapist
Psychologist
Nursing managements of patient with
stroke
1- Subjective data:
1-Important health information:
• Past health history ( cardiac problems – hypertension – diabetes)
• Medication used ( oral contraceptive – anticoagulant- antihypertensive)
2- Functional health status:
• Health perception-health management (positive family history- alcohol
and smoking)
• Nutritional – metabolic (anorexia, vomiting, dysphagia)
• Elimination ( change in bowel and bladder patterns)
• Activity – exercise ( loss of movement and sensation – weakness on
one side
• Cognitive perceptual ( numbness, tingling of one side of the body, loss
of memory, alteration in speech, pain, headache, visual disturbance
2- Objective data:
• General ( emotional liability, lethargy, apathy, and fever)
• Respiration ( airway occlusion, labored or irregular
respiration, tachypnea, apnea, loss of cough reflex.
• Cardiovascular ( hypertension, tachycardia)
• Gastrointestinal ( loss of gag reflex, bowel incontinence,
decreased or absent bowel sounds, constipation)
• Urinary ( urinary frequency, urgency, incontinence)
• Neurologic assessment ( level of consciousness,
cognition, motor ability, cranial nerve function, sensation,
cerebrall abilities , deep tendon reflex.
Glasgow coma scale
Spontaneous--open
4
Opens to verbal command, speech, or shout
3
Opens to pain, not applied to face
2
None
1
Oriented
5
Confused conversation, but able to answer questions
4
Inappropriate responses
3
Incomprehensible speech
2
None
1
Obeys commands for movement
6
Purposeful movement to painful stimulus
5
Withdraws from pain
4
Abnormal (spastic) flexion, decorticate posture
3
Extensor (rigid) response, decerebrate posture
2
None
1
Eye Opening Response
Verbal Response
Motor Response
Nursing diagnosis and intervention
Nursing diagnosis
Ineffective airway clearance
related to inability to cough
Nursing intervention
•Assess the airway for patency
•Assess for week, ineffective
cough
•Elevate the head of bed at 30c
•Auscultate chest sounds to detect
any abnormal breath sounds
•Suction as needed to remove
accumulation of secretions
•Assess the (amount, color,
consistence, and odor of sputum
•Instruct the family in feeding
program to prevent aspiration.
Nursing diagnosis
Altered tissue perfusion related to
decrease cerebral blood flow
secondary to thrombosis,
hemorrhage, edema, or spasm as
manifested by increase intracranial
pressure, and decreased Glasgow
coma scale
Nursing intervention
•Assess increase ICP
manifestation as headache,
vomiting, irritability, and disturbed
conscious.
•Administered medication as
prescribed to decrease further
development of thrombus
formation.
•Treat hypoxia and reducing pain
to prevent increase ICP.
Nursing diagnosis
Nursing intervention
Impaired verbal communication
related to aphasia as
manifested by inability to speak,
word finding problem, and use
of inappropriate words, or
inability to follow verbal
direction
•Assess communication deficits and
strengths to determine type of
communication problem and plan
appropriate intervention
•Use simple, short questions that
elicit yes or no answers, speak slowly
and allow adequate time for
response.
•Use gesture to support verbal cue
•Encourage patient to repeat the
sounds of alphabet.
•Explore the patient’s ability to write
as alternative means of
communication
•Establish alternative means of
communication
Nursing diagnosis
Impaired physical mobility related
to hemiparesis, loss of balance
and coordination, spasticity and
brain injury
Nursing intervention
•Improving mobility and preventing
joint dysfunction by:
•Maintain the patient on the correct
position to prevent contracture.
•Assist in maintain good body
alignment
•Assess and document range of
motion, transfer ability, to
determine the extent of the
problem and the appropriate
intervention
•Encourage as much self-mobility
as possible to maintain physical
activity at higher degree possible
and to promote patient sense of
comfort.
Cont..
Impaired physical mobility related
to hemiparesis, loss of balance
and coordination, spasticity and
brain injury
•Prevent shoulder adduction by
placed a pillow in the axilla while
the patient in bed.
•A pillow is placed under the arm
and the arm is placed slightly
flexed with distal joints higher the
more proximal joints to prevent
edema.
•Change patient position every 2
hours.
•Place the patient in a prone
position for 15-30 minutes several
time a day to prevent hip flexion
contracture and drain the bronchial
secretions.
Cont..
Impaired physical mobility related
to hemiparesis, loss of balance
and coordination, spasticity and
brain injury
•Preparing the patient for
ambulation is started as soon as
the patient regains consciousness.
•The patient is taught to maintain
balance while sitting and then to
learn balance while standing
•Use a wheelchair with hand brake
if needed.
•Training period should be short
and frequent. As the patient gain
strength and confidence, an
adjustable cane can be used for
support.
Nursing diagnosis
Nursing intervention
Self-care deficits related to
motor weakness, and loss
of ability to perform ADL
activities, and paralysis as
manifested by observation
or verbal report of inability
to eat, bathe, use toilet,
dress, or grooming.
•Assess and document level of self care
to determine extent of problem and plan
appropriate intervention
•Encourage independency, provide
supervision or assistance as needed to
avoid development of dependency
•The patient is encouraged to carry out all
self-care activities by use unaffected part,
such activities as combing hair, brushing
teeth, shaving with an electric razor
•Provide the patient with a small towel
after bathing is easier than big towel and
boxed paper tissue rather than the role
one.
•Encourage the family to bring suitable
clothes to the patient.
Nursing diagnosis
Nursing intervention
Unilateral neglect related to
visual field impairment and
sensory loss on one side of
the body as manifested by
consistent inattention to
stimuli on affected side .
•Assess and document amount of visual
field impairment.
•Place object in the patient field of vision
•instruct patient to turn head in the direction
of visual loss to compensate for loss of
visual field.
•Encourage the use of eye glass if available
•In case of loss of peripheral vision place
objects in center of patient’s intact visual
field
•In case of diplopia explain to the patient
the location of an object when placing it
near the patient
Nursing diagnosis
Altered urinary elimination
related to impaired impulse
to vide as manifested by
incontinence.
Nursing intervention
•Assess and document continent and
incontinent voiding to determine pattern
and plan appropriate intervention
•Intermittent catheterization with sterile
technique is carried out if the patient has
bladder atony or lost or diminished of
external urinary sphincter control
•Note color and character of urine daily
•Provide adequate amounts of fluid up to
2000ml/day unless contraindicated
•Provide the patient with a urinal in a
schedule pattern of voiding
•Frequent peIneal care to prevent UTI
Nursing diagnosis
Nursing intervention
Impaired swallowing
related to weakness or
paralysis of affected
muscle as manifested by
difficulty in swallowing and
choking
•Assess the patient to determine the
ability to swallow and the presence of gag
reflex.
•Patients must be observed for food
dribbling out of or pooling in one side of
the mouth, food retained for longer
periods in the mouth
•Advice the patient to take smaller
boluses of food, and taught about types of
food that easier to swallow
•Provide the patient with puree diet
•Instruct the patient to sit upright and tuck
the chin toward the chest as he swallows
will help prevent aspiration
•Frequent oral care should be provided
Nursing diagnosis
Nursing intervention
Self esteem disturbance
related to actual or
perceived loss of function
as manifested by
expression of shame or
guilt. Increasing
dependence on others,
refusal to participate in self
care
•Encourage patient to verbalize feelings
•Spend time with patient use good
listening techniques to show caring and
develop confidence relationship
•Establishing achievable goal, explain all
procedure and involve patient in planning
goals.
•Offer praise for every success and step
of progress
•Refer for counseling or medical
psychiatric evaluation if indicated
Nursing diagnosis
Risk for impaired skin
integrity related to
immobilization
Nursing intervention
•Frequent assessment of skin
•Use air mattress for bed ridden patient
•Skin care by using moisten lotion
•Provide the patient with regular turning
schedule
•Keep skin clean and dry
•Provide the patient with adequate
nutrition and fluid
Nursing diagnosis
Nursing intervention
Risk for ineffective
management of therapeutic
regimen related to
functional, cognitive or
communication limitation
•Assess the degree of functional,
cognitive, or communication limitations
patient is experiencing to determine
teaching plan and arrange appropriate
intervention
•Instruct patient and family how to treat,
prevent, and monitor for problems so early
intervention is ensured
•Evaluate plan to determine if regimen is
being followed or needs to be revised
based on changing patient status or
circumstances
Nursing diagnosis
Nursing intervention
Sexual dysfunction related
to neurologic deficit or fear
of failure
•Sexual dysfunction after stroke is
multifactorial, there may be cognitive
deficits, previous disease, medications or
psychological factors.
•Nurse play a crucial role in beginning a
dialogue between the patient and his or
her partner
•In-depth assessment to determined
sexual history before and after stroke
•Intervention includes education,
reassurance, adjustment of medication,
counseling regarding coping skills,
suggestion for alternative sexual
positions.
Comparison between inflammatory condition of
the brain (Meningitis & Encephalitis)
Definition
Causative
organism
Meningitis
Encephalitis
Is acute Inflammation of
the pia mater and
arachnoid membrane
surrounding the brain
and spinal cord
Acute inflammation of
the brain and it may be
May be bacterial or viral
Streptococcus
pneumonia
Haemophilus influenza
Nesseria meningitis
fatal
virus, Herpes simplex
virus, Bacteria, Fungi,
or Parasite
May occur after
complication of
Mumps, Chicken pox,
or measles
fever, severe headache,
Clinical
manifestations nausea, vomiting, and neck
rigidity, seizures, delirium,
deep stupor , and coma
Positive Brudzinski’s sign
Positive Kernig’s sign
•Gradual onset
•Headache, high
fever, seizure, and
change in level of
consciousness
Diagnostic
test
•CSF culture and analysis
•X-ray of the skull may
demonstrate infected sinus
•CT scans may reveal ICP or
hydrocephalus
•EEG, MRI, routine analysis
Viral studies
MRI
HSV DNA
Complications •Cranial nerve dysfunction with III, •Cerebral edema
IV.V.VI,VII in bacterial meningitis
usually disappears within a few
weeks.
•Hearing loss may be permanent
after bacterial infection
•Papilledema, and blindness may
occur
•Cerebral abscesses, subdural
empyema, DIC
•Mental
deterioration
•Personality change
•Hemiparesis,
seizure, behavioral
abnormality
Treatment
•Antibiotic therapy for 2 or more
weeks ( penicillin, Ampicillin or
cephalosporin
•Acetaminophen, phenytoin
•Strict bed rest, IV fluids
Nursing
assessment
•Vital signs, neurologic
evaluation, fluid intake and
output, evaluation of symptoms
Sensory perceptual alteration
Nursing
diagnosis and related to decreased LOC
intervension •Assess LOC
•Keep quite environment
•Reassure the patient
•Do not restraints to avoid
anxiety
Acyclovir (Zovirax)
are used to treat
encephalitis caused
by HSV
Supportive care
Prevention of
symptoms of ICP
Pain related to headache and
Nursing
diagnosis and joint ache, malaise
intervention •Administer mild anesthesia
•Encourage gentle range of
motion
•Massage muscle as needed
Ineffective management of
therapeutic regimen
Monitoring for residual effect of
condition such as vision,
hearing, activity, cognitive
problems to determine
appropriate referral
Hyperthermia
Risk for ICP
Risk for seizure activity
Client with Myasthenia gravis (MG
• Introduction:
Chronic neuromuscular disorder characterized
by fatigue and severe weakness of skeletal
muscles, Occurs with remissions and
exacerbations, Believed to be autoimmune in
origin, Occurs more frequently in females, with
onset between ages 20 – 30
Etiology of Myasthenia gravis (MG
• Causes by autoimmune process
Pathophysiology of Mythenia gravis
Autoimmune process
Production of antibodies destroy or block
neuromuscular junction receptor sites,
resulting in decreased number of
acetylcholine receptors
Causes decrease in muscle’s ability to
contract
Result loss of muscle strength
Clinical manifestations
• Easy fatigability of skeletal muscle during activities
• Muscle involved ( eye and eyelids, chewing, swallowing,
speaking, and breathing).
• The muscles become strongest in the morning and
become exhausted with continuous activities.
• Facial mobility and expression impaired, Difficulty in
chewing and swallowing, Speech is affected.
• The proximal muscle of neck, shoulder, and hip are more
often affected than the distal muscles.
• The course of this disease is highly variable, some patients
may stabilize and others may have sever, progressive
involvement
Complications:
•
•
•
•
Aspiration
Respiratory insufficiency
Respiratory infection
Myasthenic Crisis
Diagnostic studies
• Physical examination and history
• Tensilon Test: edrophonium chloride (Tensilon)
administered and client with myasthenia will show
significant improvement lasting 5 minutes
• Antiacetylcholine receptor antibody serum levels:
increased in 80% MG clients; used to follow course of
treatment
• Serum assay of circulating acetylcholine receptor
antibodies: if increased is diagnostic of MG
Medical managements
• Drug therapy:
• Antichcholinesterase ( Neostigmine , Mestinon)
• Corticosteroids as Prednisone
• Cytotoxic drugs such as imuran
Surgical therapy :
Thymectomy is a surgical procedure of MG
Other therapies
Plasma pheresis
Nursing managements of patient with MG
Common nursing diagnosis:
Ineffective airway clearance related to muscles weakness,
loss of gag and cough reflex
Ineffective breathing pattern related to intercostals increase
muscles weakness
Impaired verbal communication related to weakness of lips,
mouth, larynx, pharynx and jaw.
Altered nutritional state less than body requirements
related to impaired swallowing, weakness.
Activity intolerance, body image disturbance
Epilepsy
Introduction:
• Epilepsy is a group of syndromes
characterized by specific patterns of
clinical features, including age at onset,
family history, and seizure type. Types of
epilepsies are differentiated by how the
seizure activity manifests
Causes of epilepsy
•
•
•
•
•
•
Idiopathic
Genetic disorders or degenerative diseases
Birth trauma
Infectious diseases (meningitis – encephalitis)
Ingestion of toxins (mercury – CO )
BRAIN tumor, trauma, and stroke
Types of seizures
Simple partial
( flushing lights, smells, and auditory hallucination,
autonomic symptoms (sweating – flushing – pupil
dilation)
psychic symptoms ( dream state, anger, fear)
Complex partial (altered LOC, Amnesia)
Absence (A brief change in LOC indicated by blinking or
rolling
of the eyes, slight mouth movement
Myoclonic ( brief involuntary muscular jerks of the body or
extremities
Types of seizures cont..
• Generalized tonic – colonic
• ( beginning with a loud cry, change in LOC, body
stiffening, alteration between muscle spasm and
relaxation
• Tongue biting, incontinence, labored breathing, apnea,
cyanosis
• Upon wakening possible confusion and difficulty talking.
• Drowsiness, fatigue, headache, muscle soreness,
weakness.
• Atonic ( general loss of postural tone, temporary loss of
consciousness
Diagnostic tests
• CT scan and MRI
• EEG
• Serum glucose, electrolyte, calcium
and drug level
• Lumbar puncture
• Brain scan
• Cerebral angioplasty
Treatment of epilepsy
• Drug therapy: phenytoin, carbamazepine,
phenobarbital
If the drug failed the doctor may choose to
• surgically remove a demonstrated focal lesion.
• Emergency treatment for status of epilepticus (
dizepam, lorazepam, fosphentoin, 50% dextrose
IV when sezure is secondary to hypoglycemia
• Thiamine IV in chronic alcoholism or withdrawal
Nursing managements of epilepsy
• Monitor the patient for signs and symptoms of
medication toxicity, such as nystagmus, ataxia, lethargy,
dizziness, drowsiness, slurred speech, irritability,
nausea, and vomiting.
• Administer phenytoin according to guidelines not more
then 50 mg/minute and monitor the patient vital signs.
• Evaluate the patient to determine the effectiveness of
medication, seizure activity decreases or stop
• Health education