Management of Patients with Neurologic Dysfunction Chap 61

Altered Level Of Consciousness: Unresponsive to and unaware of environmental stimuli (momentary to several hours)Coma: clinical state of uncon. In which the patient is unaware of self or environment for prolonged period (days, to months, even years)Akinetic mutism: is a stat of unresponsiveness to the environment in which the pt make no movements or sound but sometimes opens the eyes.Persistent vegitative state: pt is wakeful but devoid of conscious content, without cognitive of affective mental function

Clinical Manifestations:Behavioral changes : Restlessness, or increasing anxietyChanges in Pupillary reaction: become sluggishEye openingVerbal ResponseMotor response

Altered LOC (cont...)Causes: neurlogic (head injury, stroke), toxicology, or metabolic (hepatic and renal failure, Diabetic ketoacidosis)Assessment and diagnostic findings: CT, MRI, EEG, blood glucose, electrolyte, serum ammonia, BUN, osmolarity, Ca level, PT, serum ketones. Pupillary light reflex is presented a toxic or metabolic cause is suspectedComplications: respiratory failure, pneumonia, pressure ulcer, and aspirationMedical management: Maintain patent airway, establish IV line, NGT for nutritional support, and monitoring V/S

Increased Intracranial pressure (ICP): The cranium contain: 1400g brain tissue, 75ml CSF and 75ml Blood ( these value always in state of equilibrium)Monro-Kellie hypothesis: An increase in anyone of these component causes in changes in the volume of the others by displacing or shifting of CSF, increase absorption of CSF, or decreasing cerberal blood flow volume. Without such changes, ICP will begin to rise.

ICP contMinor CSF volume and blood volume changes occur when there are changes in the intra-thoracic pressure ( coughing, sneezing, straining), posture, and blood pressure, and fluctuation in the arterial blood gases levelNormal ICP is 10 to 20 mm Hg

Pathophysiology:Increased ICP is a syndrome due to alteration of the relation between intracranial volume and pressure.

Causes: head injury (most common), brain tumors, Subarachnoid hemorrhage, and toxic and viral encephalopathy.

Increased ICP affects cerebral perfusion produce distortion, and shifts brain tissue.

Effect of Increased ICP on Brain Tissue:I. Decreased Cerebral blood flow:Cause ischemia, leading to cell death (irreversible damage), if complete ischemia lasts for 3-5 min. which can lead to further Brain EdemaIn early ischemia, vasomotor center stimulated, causing Increasing in systemic BP ( to maintain cerebral blood flow), Bradycardia (slow bounding pulse), and respiratory irregularities.Increased PaCO2 cause cerebral vasodilation, leading to increase cerebral blood flow and increased ICPDecreased venouse outflow may also increase cerebral blood volume, thus raising ICP

II. Cerebral edema:Or swelling defined as abnormal accumulation of water or fluid in the Intracellular or extracellular spaces or both, associated with an increase in brain tissue volume thus increasing ICP. Certain tumors may lead to excessive production of ADH, resulting in fluid retention. Small tumors may create a great increase in ICP.Mechanisms of compensation:I. Decrease the production and flow of CSF.II. Autoregulation:the ability of the brain to change the diameter of its blood vessels automatically to maintain a constant cerebral blood flow during alteration in systemic blood pressure.

Cerebral Response to increased ICPCompenstion made to maintain cerebral blood flow and prevent tissue damage

Brain can maintain a steady cerebral perfusion pressure (CPP) when the arterial BP is 50-150 mmHg and ICP less than 40 mmHgCerebral perfusion pressure (CPP)= mean arterial pressure - ICP =70 to 100 mm HgCPP less than 50 cause irreversible neurologic dysfunction due to decrease cerebral perfusion, cerebral ischemia and the resulting is Cushings response

Cushings response:Stimulation of Vasomotor centerLeads to rise arterial pressure to overcome the increased ICPSympathetic stimulation which leads to rising of arterial blood pressure by: A. Rising in systolic blood pressure B. widening of the pulse pressure C. Cardiac slowing: decrease heart rate

Cushings triad: bradycardia, hypertension, bradypnea. Indicates a potentially terminal event and requires emergent intervention ( failure of Autoregulation).Herniation of the brain stem and occlusion of the cerebral blood flow occure (ischemia, infarction and brain death) if therapeutic intervention is not initiated.

Clinical manifestations:Changes in the level of consciousness ( review terms and stages of altered level of consciousness)Abnormal respiratory and vasomotor responses.Restlessness, confusion, drawsnessDecortication (adduction and flexion of upper extremities, internal rotation of lower extremities and planter flexion of the feet), decerebration (extension and outward rotation of the upper extremities and planter flexion of the feet), or falcidityAt the end fixed dilated pupils and respiratory impairment which alarm death is near.

Assessment and diagnostic findings:to check the cause of Increased ICPCerebral angiography, CT-scan, MRI, or position emission tomography (PET), Transcranial dopplerLumber puncture is avoided.

Complications:Brain stem herniation, diabetes insipidus: due to decreased secretion of ADH which leads to polyurea. The patient needs fluid and electrolyte replacement and vasopresine administration syndrome of inappropriate antidiuretic hormone (SIADH): (increase secretion of ADH)which leads to fluid retention (fluid overload).phenytoin used to decrease ADH secretion, or Lithium to increase free water loss

Management:

Monitoring ICP: to identify increased pressure early, quantify the degree of abnormality, initiate appropriate treatment, provide access to CSF for sampling and drainage and to evaluate the effectiveness of the treatment.Can be monitored by: intraventricular catheter, subarachnoid (screw) bolt, an epidural or subdural catheter, or fiberoptic transducer-tipped catheter place in the brain tissue or the ventricle.Changes of ICP are indicated by waves of high pressure and normal pressure

Cont..Decrease cerebral edema: Osmotic diuretics (mannitol),corticosteriods ( dexamethasone) if the increased ICP due to brain tumor.Fluid restrictionLowering body temperature to reduce metabolic rate 3. Maintain cerebral perfusion: improvement of cardiac output.

Cont Management 4. Reducing CSF and Intracranial blood volume: hyperventilation is used to decrease the concentration of CO2 thus vasoconstriction to decrease blood volume ( PaCO2 should be maintained between 30-35 mm Hg to prevent hypoxia, ischemia, and accumulation of cerebral lactate levels)5. Controlling Fever: fever increases cerebral metabolic and the rate at which cerebral edema forms. Avoid shivering, which increase the ICPReducing metabolic demands: high doses of Barbiturates, muscle relaxants (Vecuronium bromide)Maintaing Oxygenation

Intracranial Surgery: A craniotomy involves opening the skull surgically to gain access to intracranial structure ( supratentorial, infratentorial, and transsphenoidal approach).Preoperative Evaluation: CT, MRI, Cerebral angiography, and transcranial Doppler flow studies.Complications: Increased ICP, infection, and neurologic deficit.

Preoperative Management:

Anticonvulsant therapy to prevent postoperative seizures Steroids to decrease cerebral edemaFluid may be restrictedHyperosmotic agent and diuretics may be given immediately before and sometimes during surgeryInsert folly catheterCentral line may administered for fluid administration and central venous pressure monitoring after surgeryAntibiotics and diazepamPreparation the site of the surgery

Postoperative Management:Reducing cerebral edemaRelieving pain and SeizuresMonitoring ICP

Nursing Management:Evaluating the level of consciousness and responsiveness to stimuli and identify any neurologic deficit.Patient and family educationPreparation for surgery: Psychological supportPostoperative: assessment and routine nursing care

Headache or Cephalgia

Symptoms rather than disease and may indicate organic disease.Primary headache: no identified cause such as migraine and cluster headacheSecondary headache: due to organic cause such as tumor or aneurysm

Assessment and diagnostic findings: detailed history, physical examination of head and neck and complete neurologic examination , headache may be a symptom of endocrine, hematologic, gastrointestinal, infection, renal, cardiovascular, and psychiatric diseaseMedication history: antihypertensive, anti-inflamatoryStress

Migraine:Periodic and recurrent attacks of sever headache.Vascular disturbances more commonly in women and has strong familial tendency. Incidence highest in adults 20-35 yearsPathophysiology: varying degrees of cortical ischemia followed by vasodilation.Abnormal metabolism of Serotonin ( Vasoactive neurotransmitter). Rise in plasma seratonin, dilate the extracranial carotid artery and constrict the intracranial carotid artery. This process is followed by a fall in plasma seratonin (vasodilation) and a pulsating, throbbing pain.Headache can be triggered by menstrual cycle, bright light, stress, depression, sleep deprivation, fatigue, over use of certain medication such as oral contraceptive, and some milk product.

Clinical manifestations:

The headache often start early morning Prodome phase: symptoms occur hours to days before a migraine headache ( depression, irritability, feeling cold, food craving, anorexia, changes in activity level, increased urination, diarrhea or constipationAura phase: last less than one hour: visual disturbances (light flashes and bright spots, numbness and tingling of the lips, face, or hands, mild confusion, slight weakness, drowsiness, and dizziness.

ContHeadache phase: a vasodilation and a decline in seratonin levels occur, throbbing headach (unilateral) intensive for several hours, associated with photophobia, nausia, and vomiting (4-72 hours)Recovery phase: the pain gradually subsides, muscle contraction in the neck and scalp, muscle ache, exhaustion, and mood changes. During this phase, pt may sleep for extended periods

Prevention:Avoid specific triggers that are known to initiate the headache syndrome.Medication therapy: Propranolol ( inderal) the mostly wide used medication, calcium antagonists ( Verapamil HCL), Methysegide (Sansert) block the effect of seratonin, Anticonvulsants, antidepressent, barbiturates, tranquilizer.Avoid vasodilators, alcohol, nitrites, and histaminesMedical management:Symptomatic:And preventiveNursing management:Administer medication to relieve painComfort measures (quite dark environment and elevation of the head of the bed 30 degree

Chap 62

Management of patients with Cerebrovascular Disorders

Cerebrovascular DisordersFunctional abnormality of the CNS that occurs when the blood supply is disrupted Stroke is the primary cerebrovascular disorder and the third leading cause of death in the U.S.Stroke is the leading cause of serious long-term disability in the U.S.Direct and indirect costs of stroke are $53.6 billion

PreventionNonmodifiable risk factorsAge (over 55), male gender, African American raceModifiable risk factors: see Chart 62-1Hypertension: the primary risk factor Cardiovascular diseaseElevated cholesterol or elevated hematocritObesityDiabetes Oral contraceptive useSmoking and drug and alcohol abuse

StrokeBrain attackSudden loss of function resulting from a disruption of the blood supply to a part of the brainTypes of stroke: see Table 62-1Ischemic (80% to 85%) Hemorrhagic (15% to 20%)

Ischemic StrokeDisruption of the blood supply due to an obstruction, usually a thrombus or embolism, that causes infarction of brain tissueTypesLarge artery thrombosisSmall penetrating artery thrombosisCardiogenic embolismCryptogenic (unknown cause Other such as cocain use, coagulopathies, migraine

Manifestations of Ischemic StrokeSymptoms depend upon the location and size of the affected area Numbness or weakness of face, arm, or leg, especially on one side Confusion or change in mental statusTrouble speaking or understanding speechDifficulty in walking, dizziness, or loss of balance or coordinationSudden, severe headachePerceptual disturbancesSee Tables 62-2 and 62-3

Cerebrovascular TermsHemiplegiaHemiparesis Dysarthria: difficulty in speaking (muscle paralysis)Aphasia: expressive aphasia, receptive aphasiaHemianopsia: Loss of half visual field Apraxia: inability to perform previously learened actions.

Transient Ischemic Attack (TIA)Temporary neurologic deficit resulting from a temporary impairment of blood flowWarning of an impending strokeDiagnostic work-up is required to treat and prevent irreversible deficits

Assessment and diagnostic findings:CT, MRI, EEG, carotid ultrasound, cerebral angiographyPrevention: alter the risk factors, administration of anticoagulantsComplications: Cerebral hypoxia, decreased cerebral blood flow, extension of the affected area

Preventive Treatment and Secondary PreventionHealth maintenance measures including a healthy diet, exercise, and the prevention and treatment of periodontal diseaseCarotid endarterectomyAnticoagulant therapy Antiplatelet therapy: aspirin, dipyridamole (Persantine), clopidogrel (Plavix), and ticlopidine (Ticlid)StatinsAntihypertensive medications

Medical Management:I. Thrombolytic therapy : should be administer within 3 hours of stroke attackt-PA (tissue plasminogen activator: is an example. Stimulate firbinolysis of the atherosclerotic lesionPt preparation for t-PA: Definitive Diagnosis of ischemiaPt meeting the criteria for the t-PA (Chart 62-3- p 1893)Preparation of the dose (0.9 mg/kg, the maximum dose is 90 mg), 10% of the dose given over one min the remaining dose is administered over one hour via an infusion pump, the line then infused with 20 ml normal saline

ContPt care post t-PA: admit the pt to ICU, Cont. cardiac monitoring, V/S every 15 min for the first 2 hrs, every 30 min for the next 6 hrs, then every hrs for the next 16 hrs, systolic BP should maintained less than 180mmHg, and diastolic BP less than 100 mmHg, start airway management.Side effects of t-PA: is Bleeding

Therapy for pt with ischemic stroke not receiving t-PA:Maintain of pt airway, and administer of supplemental O2Administer of Anticoagulant agentMaintain a cerebral hemodynamics, Decrease ICP if occur (mannitole, maintain PaCO2 within 30-35 mmHg, and avoiding hypoxia, elevation of the head of the bedCarotid endarterectomy: it is the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in the pt with occlusive disease of the extracranial cerebral ateries. Neurological assessment

Therapy For Complications: maintaining cardiac output within the normal range of 4-8L/min to improve cerebral perfusion and oxygenation to prevent hypoxia and ischemia, maintenance of airway and administer supplemental O2

Carotid Endarterectomy

Nursing ProcessAssessing the Patient Recovering From an Ischemic StrokeAcute phase Ongoing/frequent monitoring of all systems including vital signs and neurologic assessment: LOC and motor, speech, and eye symptomsMonitor for potential complications including musculoskeletal problems, swallowing difficulties, respiratory problems, and signs and symptoms of increased ICP and meningeal irritationAfter the stroke is completeFocus on patient function; self-care ability, coping, and teaching needs to facilitate rehabilitation

Nursing ProcessDiagnosis of the Patient Recovering From an Ischemic StrokeImpaired physical mobilityAcute painSelf-care deficitsDisturbed sensory perceptionImpaired swallowingUrinary incontinence

Nursing ProcessDiagnosis of the Patient Recovering From an Ischemic Stroke (cont.)Disturbed thought processesImpaired verbal communicationRisk for impaired skin integrityInterrupted family processesSexual dysfunction

Collaborative Problems/Potential ComplicationsDecreased cerebral blood flowInadequate oxygen delivery to brainPneumonia

Nursing ProcessPlanning Patient Recovery After an Ischemic StrokeMajor goals include: Improved mobility Avoidance of shoulder painAchievement of self-care Relief of sensory and perceptual deprivation Prevention of aspirationContinence of bowel and bladder

Nursing ProcessPlanning Patient Recovery After an Ischemic Stroke (cont.)Major goals include (cont):Improved thought processesAchievement of a form of communicationMaintenance of skin integrity Restoration of family functioning Improved sexual function Absence of complications

InterventionsFocus on the whole personProvide interventions to prevent complications and to promote rehabilitationProvide support and encouragementListen to the patient

Improving Mobility and Preventing Joint DeformitiesTurn and position the patient in correct alignment every 2 hoursUse splintsPractice passive or active ROM 4 to 5 times dayPosition hands and fingersPrevent flexion contractures Prevent shoulder abductionDo not lift by flaccid shoulderImplement measures to prevent and treat shoulder problems

Positioning to Prevent Shoulder Abduction

Prone Positioning to Help Prevent Hip Flexion

Improving Mobility and Preventing Joint Deformities Perform passive or active ROM 4 to 5 times dayEncourage patient to exercise unaffected sideEstablish regular exercise routineUse quadriceps setting and gluteal exercisesAssist patient out of bed as soon as possible: assess and help patient achieve balance and move slowlyImplement ambulation training

InterventionsEnhance self-careSet realistic goals with the patientEncourage personal hygieneEnsure that patient does not neglect the affected sideUse assistive devices and modification of clothing Provide support and encouragementImplement strategies to enhance communication: see Chart 62-4Encourage the patient with visual field loss to turn his head and look to side

Interventions (cont.)Nutrition Consult with speech therapist or nutritionistHave patient sit upright to eat, preferably OOBUse chin tuck or swallowing methodFeed thickened liquids or pureed dietBowel and bladder controlAssess and schedule voidingImplement measures to prevent constipation: fiber, fluid, and toileting scheduleProvide bowel and bladder retraining

Hemorrhagic StrokeCaused by bleeding into brain tissue, the ventricles, or subarachnoid space May be due to spontaneous rupture of small vessels primarily related to hypertension;Subarachnoid hemorrhage due to a ruptured aneurysm; or intracerebral hemorrhage related to amyloid angiopathy, arterial venous malformations (AVMs), intracranial aneurysms, or medications such as anticoagulants

Hemorrhagic Stroke (cont.)Brain metabolism is disrupted by exposure to bloodICP increases due to blood in the subarachnoid spaceCompression or secondary ischemia from reduced perfusion and vasoconstriction injures brain tissue

ManifestationsSimilar to ischemic strokeSevere headacheEarly and sudden changes in LOCVomitingPain and rigidity of the neck and the back and spineVisual disturbances (visual loss, diplopia, ptosis) may occurTinnitus, dizziness, and hemiparesis may occur.

Medical ManagementPrevention: control of hypertensionDiagnosis: CT scan, cerebral angiography, and lumbar puncture if CT is negative and ICP is not elevated to confirm subarachnoid hemorrhageCare is primarily supportiveBed rest with sedation OxygenTreatment of vasospasm, increased ICP, hypertension, potential seizures, and prevention of further bleeding

Intracranial Aneurysms

Aneurysm PrecautionsAbsolute bed restElevate HOB 30 to promote venous drainage or keep the bed flat to increase cerebral perfusionAvoid all activity that may increase ICP or BP; implement Valsalva maneuver, acute flexion, and rotation of the neck or headExhale through mouth when voiding or defecating to decrease strain

Aneurysm Precautions (cont.)Nurse provides all personal care and hygieneProvide nonstimulating, nonstressful environment: dim lighting, no reading, no TV, and no radioPrevent constipationRestrict visitors

InterventionsRelieve sensory deprivation and anxietyKeep sensory stimulation to a minimum for aneurysm precautionsImplement reality orientationProvide patient and family teachingProvide support and reassuranceImplement seizure precautionsImplement strategies to regain and promote self-care and rehabilitation

Home Care and Teaching for the Patient Recovering From a StrokePrevention of subsequent strokes, health promotion, and implementation of follow-up carePrevention of and signs and symptoms of complications Medication teachingSafety measuresAdaptive strategies and use of assistive devices for ADLs

Home Care and Teaching for the Patient Recovering From a Stroke (cont.)Nutrition: diet, swallowing techniques, and tube feeding administrationElimination: bowel and bladder programs and catheter useExercise and activities: recreation and diversionSocialization, support groups, and community resourcesSee Chart 62-6

Nursing ProcessAssessment of the Patient With a Hemorrhagic Stroke/Cerebral AneurysmComplete an ongoing neurologic assessment: use neurologic flow chartMonitor respiratory status and oxygenationMonitor ICPMonitor patients with intracerebral or subarachnoid hemorrhage in the ICUMonitor for potential complicationsMonitor fluid balance and laboratory dataReported all changes immediately

Nursing ProcessDiagnosis of the Patient With a Hemorrhagic Stroke/Cerebral AneurysmIneffective tissue perfusion (cerebral)Disturbed sensory perceptionAnxiety

Collaborative Problems/Potential ComplicationsVasospasmSeizuresHydrocephalus RebleedingHyponatremia

Nursing ProcessPlanning Care of the Patient With a Hemorrhagic Stroke/Cerebral AneurysmGoals may include: Improved cerebral tissue perfusion Relief of sensory and perceptual deprivation Relief of anxiety Absence of complications

Chapter 64

Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies

MeningitisInflammation of the membranes and the fluid space surrounding the brain and spinal cordTypes:Septic due to bacteria (Streptococcus pneumoniae, Neisseria meningitidis)Aseptic due to viral infection, lymphoma, leukemia, or brain abscess

ContN. meningitidis is transmitted by secretions or aerosol contamination, and infection is most likely in dense community groups such as college campusesManifestations include headache, fever, changes in LOC, behavioral changes, nuchal rigidity (stiff neck), positive Kernig's sign, positive Brudzinskis sign, and photophobia

Kernigs Sign

Brudzinskis Sign

Medical Management Prevention by vaccination against H. influenzae and S. pnuemoniae for all children and at-risk adultsEarly administration of high doses of appropriate IV antibiotics for bacterial meningitis Dexamethasone Treatment dehydration, shock, and seizures

Nursing ManagementConduct frequent/continual assessment including VS and LOCProtect patient form injury related to seizure activity or altered LOCMonitor daily weight, serum electrolytes, urine volume, specific gravity, and osmolalityPrevent complications associated with immobility Take infection control precautionsProvide supportive careImplement measures to facilitate coping of the patient and family

Cranial Nerve Disorders:Trigeminal Neuralgia ( Tic Douloureux..painful twitch):Is a condition of fifth cranial nerve characterized by pain similar to an electric shock or burning sensation in the area innervated by one or more branches of the trigeminal nerve.Pain is stabbing, lasting from a few seconds to minutes felt in the skin not deep), and produces contraction of some facial muscles, such as closing of the eye or a twitching of the mouth.Predisposing factors: stimulation of the terminal of any affected nerve branch by washing the face, shaving, brushing the teeth, eating, drinking, cold air, direct pressure

Distribution of the Trigeminal Nerve Branches

Medical management:

Pharmacological: Anticonvulsant (tegretol), phenytoin, alcohol or phenol injection to the peripheral branch relieves pain for several months antispasmodic medication baclofen (Lioresal)Surgical management A. Percataneous radiofreguency trigeminal Gangliolysis: fibers are thermally destroyed B. Microvascular decompression of the trigeminal nerve ( an intracranial approach to decompress the trigeminal nerve ( vascular compression)

Nursing InterventionsPatient teaching related to pain prevention and treatment regimenMeasures to reduce and prevent pain; avoidance of triggersCare of the patient experiencing chronic painMeasures to maintain hygiene: washing face, oral careStrategies to ensure nutrition: soft food, chew on unaffected side, and avoid hot and cold food Recognize and provide interventions to address anxiety, depression, and insomnia

Bells PalsyFacial paralysis due to unilateral inflammation of the 7th cranial nerveManifestations: unilateral facial muscle weakness or paralysis with facial distortion, increased lacrimation, painful sensations in the face, and possible difficulty with speech and eatingMost patients recover completely in 3 to 5 weeks, and the disorder rarely recurs

ManagementMedical Corticosteroid therapy may be used to reduce inflammation and diminish severity of the disorderNursingProvide and reinforce information and reassure patient that a stroke has not occurred Protect the eye from injury, cover the eye with a shield at night, and instruct the patient to close the eyelid, use eye ointment, and wear sunglassesImplement facial exercises and massage to maintain muscle tone

Seizures:Episode of abnormal motor, sensory, autonomic or psychic activity or a combination of these.Most are sudden and transient. Cause: sudden excessive discharge from cerebral neurons (electrical disturbance)Types:Partial seizures: A part of brain is affectedGeneralized seizures: electrical discharges in the whole brain.

Causes of electrical disturbances:IdiopathicAcquired: Hypoxemia, fever, head injury, hypertension, CNS infection, brain tumor, drug and alcohol withdrawal, allergies, and metabolic and toxic conditions (renal failure, hyponatremia, hypoglycemia, hypocalcemia, and pesticides)

Manifestations:LocExcess movementOr loss of movementDisturbance of behavior (mood, sensation, and perception

Nursing Management:During a seizure:Provide PrivacyEase the patient to the floor if possibleProtect the head with badLoosen constrictive clothingRemove pillows and raise the side rails

Cont6. If the aura (visual, auditory, or olfactory) stage precedes the seizures, insert an oral way7. Do not attempt to insert anything to open mouth during the seizure episode8. Do not attempt to restrain the patient9. If possible place the patient on one-side with head flexed forward.

Nursing care after the Seizure:Keep the patient on one-side to prevent aspiration. Make sure the airway is patientThere is usually a period of confusion after agrand mal seizure A short apeinic period may occur during or immediately after a generalized seizureReorient the patient to the environmentIf the patient becomes agitated after a seizure, use calm persuasion and gentle restrain

Autoimmune Neurologic DisordersMultiple sclerosis Myasthenia gravis Guillain-Barr syndrome

Multiple Sclerosis (MS)A progressive immune-related demyelination disease of the CNSClinical manifestations vary and have different patternsFrequently, the disease is relapsing and remitting, has exacerbations and recurrences of symptoms including fatigue, weakness, numbness, difficulty in coordination, loss of balance, pain, and visual disturbancesMedical managementDisease-modifying therapies; interferon -1a and interferon -1b, glatiramer acetate (Copaxone), and IV methylprednisolone Symptom management of muscle spasms, fatigue, ataxia, bowel and bladder control

Process of DemyelinationRefer to fig. 64-3

Parkinsons DiseaseAssociated with decreased levels of dopamine due to destruction of cells in the substantia nigra in the basal ganglia; this effects the neurotransmission of impulsesManifestations: tremor, rigidity, bradykinesia, postural instability, depression and other psychiatric changes, dementia, autonomic symptoms, sleep disturbances, Medical management Pharmacologic treatmentSurgical proceduresOther therapies

Pathophysiology of Parkinsons Disease

Nursing Process: The Care of the Patient with Parkinsons DiseaseAssessment

Focus on the degree of disability and function of the patient including ADLs, IADLS, and cognitive functionMedications and responses to medicationsEmotional responses and individual coping Family processes and copingHome care and teaching needsFall risk assessmentManifestations and potential complications related to the specific disorder

Nursing Process: The Care of the Patient with Parkinsons DiseaseDiagnosesImpaired physical mobility and risk for activity intoleranceDisturbed thought processesSelf-care deficits Imbalanced nutritionConstipationImpaired verbal communicationIneffective coping and compromised family copingDeficient knowledgeRisk for injury

Nursing Process: The Care of the Patient with Parkinsons DiseasePlanningMajor goals may include improved functional ability, maintaining independence in activities of daily living, achieving adequate bowel elimination, attaining and maintaining acceptable nutritional status, achieving effective communication, developing positive individual and family coping skills.

Improving Mobility Daily program of exerciseROM exercisesPostural exercisesConsultation with physical therapyWalking techniques for safety and balanceFrequent rest periodsProper shoes Use of assistive devices

InterventionsEnhancing self-care ability Encourage, teach, and support independenceEnvironmental modificationsUse of assistive and adaptive devices Consultation with occupational therapySupport of copingSet achievable, realistic goalsEncourage socialization, recreation, and independencePlanned programs of activitySupport groups and referral to supportive services- counselors, social worker, home care

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