Microsoft Power Point Neuro Disorders

NEUROLOGIC DISORDERS

NIO C. NOVENO, RN, MAN, MSN

ALZHEIMER’S DISEASEALZHEIMER’S DISEASE

ALZHEIMER’S DISEASE

A progressive, degenerative neurological disorder characterized by:

Behavioral dysfunctionSevere cognitive impairmentSevere cognitive impairment

Personality changes

Most common non-reversible form of dementia� Forgetfulness → mental incapacitation

nionoveno@ycNEUROLOGIC DISORDES 3


Degenerative disorder of the cerebral cortex

(frontal lobe)

Poor prognosisPoor prognosis

No cure or definitive treatment



Pathophysiolgy…

Brain damage caused

Chromosome 21


Neurofibril tangles

Neuritic plaques Granulovacuolar degeneration

Brain damage caused genetic substance

(amyloid)

1

2


3


Risk factors

� Neurochemical

� Environmental� Aluminum and manganese

� Slow-growing CNS viruses

� Trauma

� Genetic abnormality (C 21)

� Old age


ALZHEIMER’S DISEASE: Symptoms

Stage 1: 1-3 years•Short-term memory loss

•Decreased attention span

•Subtle personality changes

•Mild cognitive deficits

•Difficulty with depth

perception

Stage 2: 2-10 years•Obvious memory loss

•Confusion

•Wandering behavior


perception •Wandering behavior

•“Sundowning”

•Irritability and agitation

•Decreased spatial

orientation

•Impaired motor skills

•Impaired judgment

Stage 3: 8-10 years•Absent cognitive abilities

•Disoriented to time & place

•Severely altered communication

skills

•Impaired or absent motor skills

•Bowel & bladder incontinence

NURSING CARE

Prevent injury

Safe environment

Assess changes in mental status

Maintain improve hygiene, nutrition, healthMaintain improve hygiene, nutrition, health

Labels

Keep routines

Frequent rest periods

Encourage exercises to maintain mobility

Provide emotional support to the family


Pharmacology

Anti-cholinesterase1. Tacrine HCl (Cognex)

� Check liver function weekly x 18 weeks

2. Donepezil (Aricept)� OD in the early stages

3. Rivastigmine 3. Rivastigmine

Cholinergics[Ach precursors: choline, lecithin, deanol]

Anti-depressantsAmitriptyline, desipramine, fluoxetine, nortryptilline, trazodone


Pharmacology

Vitamin E & selegiline

� Delay the progress of AD

Ginkgo bilobaGinkgo biloba

� Improves cognitive function for 6-12 mos.

Propentofylline


Pharmacology

Anti-psychotics

� Haloperidol (Haldol): agitation and confusion

� Taken HS

� A/E: WOF extrapyramidal symptoms (EPS)� A/E: WOF extrapyramidal symptoms (EPS)


Pharmacology

CORTICAL CHANGES

ABSENT COGNITIVE ABILITIES

LABELSLABELSIMPROVE COGNITION

MAINTAIN A NORMAL LIFESTYLE

OLD AGE

TACRINE


PARKINSON’S DISEASEPARKINSON’S DISEASE(PARALYSIS AGITANS)(PARALYSIS AGITANS)

Motor Motor modulationmodulation


Motor cortex: Planning & initiationMotor cortex: Planning & initiation

Cerebellum: Motor coordinationCerebellum: Motor coordination

Parkinson's Disease (Paralysis Agitans)

A. Etiology and pathophysiology

1. Progressive disorder:

bradykinesia, tremor, rigidity (BRT)

� ♂ than ♀ (3:2)� ♂ than ♀ (3:2)

2. Suspected causes include:

a. neuromuscular imbalance

(dopamine and acetylcholine)

b. unknown virus

c. cerebral vascular disease

d. chemical or physical trauma


PATHOPHYSIOLOGY

Dopamine producing neurons degenerate▼

Depletion of dopamine & excess acetylcholine

▼▼

Basal ganglia further deteriorates� Initiate movement� Control posture

� Maintain muscle tone� Autonomic movements

SYMPTOMS DO NOT APPEAR UNTIL 70-80% OF SUBSTANTIA NIGRA NEURONS ARE LOST



B. Clinical findings

1. Subjective

a. Mild, diffuse, muscular pain

b. Feelings of stiffness and rigidity, particularly of b. Feelings of stiffness and rigidity, particularly of

large joints

c. Defects in judgment and emotional lability

may be present

d. Depression

e. Cognitive and memory deficits


Parkinson's Disease (Paralysis Agitans)2. Objective

a. Increased difficulty in performing usual activities

b. Generalized tremor; "pill-rolling“

c. Various disorders of locomotion c. Various disorders of locomotion

d. Mask-like facial expression with unblinking eyes

e. Low-pitched, slow, poorly modulated, poorly articulated speech

f. Drooling

g. Various autonomic symptoms

h. In the elderly, dementia, confusion, and psychosis


PARC DARKPARC DARKPPILL ROLLING

AABOUT TO FALL

RRIGIDITY

CCAN’T SWALLOW/SPEAK (DROOLS)


DDOPAMINE/L-DOPA

AARTANE

RRESTRICT COFFEE

KKEEP TREMORS DOWN (ANTI-H1)


C.Therapeutic interventionsMedical regimen is palliative rather than curative

1. Levodopa [coverts to dopamine] + Carbidopa (Sinemet) [prevents brekdown of levodopa](Sinemet) [prevents brekdown of levodopa]� Decrease CHON in diet

� Withheld until symptoms become disabling

� SE: dyskinesias, hallucinations, and nightmares, orthostatic hypotension, NV



2.Dopamine agonists: postpone initiation of levodopa and carbidopa therapytherapy� Pergolide (Permax)

� Bromocritine mesylate (Parlodel)

� Ropinirole

� Pramipexole



3. Anticholinergic agents

4. Amantadine HCl (Symmetrel) – unknown

mechanism in PDmechanism in PD

5. MAO inhibitors – increases dopamine levels

� Selegiline (Elepryl)



6. Budipine

� Reduces akinesia, rigidity and tremors

7. Anti-histamine7. Anti-histamine

� Allays tremors

8. Physiotherapy to reduce rigidity of

muscles and prevent contractures



Surgical intervention

a. Thalamotomy – stereotactic surgical technique which localizes and destroys VL thalamic nucleus

b. Pallidotomy – experimental procedure for intractable procedure

c. Fetal neural tissue transplant to basal ganglia (experimental)



Complications Fluctuations in mobility

1. Wearing-off effects

2. On-off symptoms – unpredictable symptoms of rapid fluctuation between dyskinesia (“on” rapid fluctuation between dyskinesia (“on” symptoms) and rigidity or bradykinesia (“off” symptoms)

3. Psychiatric effects

� Confusion� Visual hallucinations

� Paranoia 4. Sleep disturbances



Prognosis:

• NO cure

• Slowly progressive• Slowly progressive

• Declines over several years


Nursing Care of Clients with Parkinson's DiseaseAssessment

1. History of onset and progression of symptoms

2. Observations of tremors, gait, facial expression, and bradykinesia and bradykinesia

3. Nutritional status

4. Elimination status

5. Blood pressure in horizontal and vertical positions to identify postural hypotension


Nursing Care of Clients with Parkinson's DiseasePlanning/Implementation

1. Provide a safe environment

2. Teach the client or family to cut food into small bite-sized pieces or alter the consistency to prevent choking sized pieces or alter the consistency to prevent choking

3. Provide small, frequent meals

4. Encourage an adequate intake of roughage and fluids

5. Teach the client activities to limit postural deformities


Nursing Care of Clients with Parkinson's DiseaseC. Planning/Implementation cont…

6. Teach the client activities to maintain gait as normal as possible

7. Teach and encourage daily physical therapy to limit rigidity 7. Teach and encourage daily physical therapy to limit rigidity and prevent contractures

8. Attempt to administer care

9. Encourage the client to continue taking medications even though results may be minimal

10. Advise client to report side effects to physician


Nursing Care of Clients with Parkinson's Disease

11. Encourage diet rich in nutrient-dense foods

12. Teach clients taking levodopa to limit intake 12. Teach clients taking levodopa to limit intake of foods high in vitamin B6

13. Assist client in setting achievable goals

14. Suction when necessary


(Lou Gehrig Disease)(Lou Gehrig Disease)

Amyotrophic Lateral SclerosisAmyotrophic Lateral Sclerosis

Amyotrophic Lateral Sclerosis(Lou Gehrig’s Disease)

Etiology and pathophysiology

1. Cause unknown2.Progressive degenerative process involving the spinal, corticobulbar, and lower motor the spinal, corticobulbar, and lower motor

neurons, with subsequent atrophic and spastic

changes in the cranial as well as the spinal

nerves

3.Occurs more frequently in men than in women in the fourth and fifth decades of life



Clinical findings

1. Subjective

a. Muscular weakness

b. Malaise and fatigue

2.Objective

a. Irregular spasmodic twitching in small muscle groups

(fasciculations)

b. Atrophy

c. Spasticity

d. Difficulty in breathing, chewing, swallowing, speaking

e. Outbursts of laughter or crying



C. Therapeutic interventions

1. Physiotherapy may be helpful in relieving

spasticityspasticity

2. Support respiratory functions


Nursing Care of Clients with Amyotrophic Lateral SclerosisA. Assessment

1. History of onset and progression of

symptoms

2. Neurologic status

3. Respiratory status including rate, depth, and

effort


Nursing Care of Clients with Amyotrophic Lateral SclerosisC. Planning/Implementation

1. Encourage activity

2. Encourage range-of-motion exercises

3. Prevent aspiration 3. Prevent aspiration

4. Provide alternate means of communication

5. Allow client to discuss feelings

6. Monitor respiratory function

7. Support natural defense mechanisms

8. Teach the avoidance of situations that may

contribute to infection


Myasthenia Gravis

A. Etiology and pathophysiology1. A chronic, progressive, neuromuscular disorder

2. Reduced number of acetylcholine receptors (AChR) and altered membrane of the muscle end-(AChR) and altered membrane of the muscle end-plate

3. Autoimmune process

4. Highest incidence in young adult females


Myasthenia Gravis

A. Etiology and pathophysiology cont…

5. Myasthenic crisis

6. Two peaks of onset:6. Two peaks of onset:

� 20-30 years: ♂than♀� >50 years: ♀than ♂


Myasthenic crisis

Abrupt onset of severe, generalized muscle weakness

with inability to swallow, speak or maintain

respirations

Administration of Tensilon provide relief

Cholinergic crisisCholinergic crisis

Symptoms similar to myasthenic crisis and also, the side

effect of anticholinesterase drugs

Administration of Tensilon worsen the symptoms


Myasthenia Gravis

A. Etiology and pathophysiology cont…

7. Risk factors

a. Stress

b. Hormonal changesb. Hormonal changes

c. Drugs

• Alcohol

• Aminoglycosides

• Morphine


Pathophysiology

Thymic lymphocytes▼

Acetylcholine-receptor antibodies ▼

Attack post synaptic muscle membraneAttack post synaptic muscle membrane▼

Fewer receptors to combine with acetylcholine▼

Altered action potential▼

Weakness


Myasthenia GravisB. Clinical findings

1. Subjective

a. Extreme muscle weakness

• progressively worsens as the muscle is used, but disappears with rest

b. Dysphagia (difficulty chewing and swallowing) b. Dysphagia (difficulty chewing and swallowing)

c. Diplopia

d. Dysarthria (difficulty speaking)

e. Dyspnea


Myasthenia Gravis

2. Objective

a. Ptosis

b. Weak voice (dysphonia)

c. Myasthenic smile (snarling, nasal smile)c. Myasthenic smile (snarling, nasal smile)

d. Strabismus

e. Diagnostic measures

� TENSILON TEST: Edrophonium is used to

distinguish myasthenic crisis from cholinergic

crisis (toxic effects of excessive neostigmine)


Myasthenia Gravis

C. Therapeutic interventions1. Anticholinesterases

a. Neostigmine (Prostigmin)

b. Pyridostigmine bromide (Mestinon)

c. Ambenonium chloride (Mytelase)

2. X-ray therapy or thymectomy may cause partial remission

3. Corticosteroids or ACTH

4. Tracheostomy with mechanical ventilation

5. Plasmapharesis


Nursing Care of Clients with Myasthenia Gravis

A. Assessment1. History of onset and progression of motor

and sensory loss and sensory loss

2. Factors that intensify symptoms



Nursing Care of Clients with Myasthenia GravisC. Planning/Implementation

1. Administer medications on strict time schedule

2. Observe for signs of:� Dyspnea

� Dysphagia ► myasthenic crisis� Dysphagia ► myasthenic crisis� Dysarthria

3. T-SET on bed side

4. Provide plenty of rest

5. Avoid people with URTI


Nursing Care of Clients with Myasthenia Gravis

6. Carry a medic alert band

7. NO morphine

8. Allay anxiety

9. Proper nutrition

10. Prevent corneal damage


GUILLAINGUILLAIN--BARRÉ SYNDROME BARRÉ SYNDROME (POLYRADICULONEURITIS)(POLYRADICULONEURITIS)

Guillain-Barré Syndrome

(Polyradiculoneuritis)A. Etiology and pathophysiology

1. Cause unknown; � immunologic status

� follows respiratory or gastrointestinal infection

2. Changes in the motor cells of the spinal cord and medulla with areas of demyelination

3. After initial and plateau periods, recovery may take up to a year� some experience residual deficits or die of complications



(Polyradiculoneuritis)B. Clinical findings

1. Subjective

a. Generalized weakness

b. Paresthesia

c. Diplopia

2. Objective

a. Ascending paralysis; 24-72 hours

b. Respiratory paralysis

c. Hypertension, tachycardia, and low-grade fever

d. Incontinence



(Polyradiculoneuritis)C. Therapeutic interventions

1. Steroids

2. Plasmapheresis2. Plasmapheresis

3. Support of vital functions



(Polyradiculoneuritis)Nursing Care of Clients with Guillain-Barré

Syndrome

Assessment1. Respiratory characteristics1. Respiratory characteristics


3. History of any recent illness (particularly viral infections)

4. Onset and progression of symptoms



(Polyradiculoneuritis)Nursing Care of Clients with Guillain-Barré Syndrome

Planning/Implementation

1. Monitor vital signs, vital capacity, breath sounds,

and arterial blood gasesand arterial blood gases

2. Keep airway and tracheostomy set at the bedside

3. Suction, provide fluid replacement therapy, and

monitor functioning of the respirator as required



(Polyradiculoneuritis)Nursing Care of Clients with Guillain-Barré Syndrome

Planning/Implementation

5. Prevent complications of immobility

a. Skin carea. Skin care

b. Range-of-motion exercises

c. Position changes

d. Coughing and deep breathing

e. Antiembolic stockings


MULTIPLE SCLEROSIS MULTIPLE SCLEROSIS (DISSEMINATED SCLEROSIS)(DISSEMINATED SCLEROSIS)

Multiple Sclerosis (Disseminated Sclerosis)A. Etiology and pathophysiology

1. Chronic, debilitating, progressive disease� periods of remission and exacerbation

� randomly scattered patches of demyelination

� brainstem, cerebrum, cerebellum, and spinal cord� brainstem, cerebrum, cerebellum, and spinal cord

2. Cause unknown; viral and immunologic

3. Onset in early adult life (20 to 40 years)

4. Fatigue, stress, and heat tend to increase symptoms


Multiple Sclerosis (Disseminated Sclerosis)B. Clinical findings

1. Subjective

a. Paresthesia

b. Altered position sense b. Altered position sense

c. Dysphagia

d. Ataxia

e. Weakness

f. Diplopia

g. Blurred vision

h. Inappropriate emotional affect


Multiple Sclerosis (Disseminated Sclerosis)

2. Objectivea. Nystagmus

b. Blindness

c. Intention tremors

d. Slurred or scanning speech

e. Spastic paralysis and gaite. Spastic paralysis and gait

f. Impaired bowel function

g. Impaired bladder function

h. Impotence

i. Cognitive loss (a late sign)

j. Increased deep tendon reflexes

k. Pallor of optic discs evident on examination with ophthalmoscope

l. Increased gamma globulin levels in the CSF


Multiple Sclerosis (Disseminated Sclerosis)C. Therapeutic interventions

1. Generally palliative

2. Corticosteroids or ACTH

3. Baclofen is used to control spasticity 3. Baclofen is used to control spasticity

4. Interferon beta-1b, recombinant (Betaseron)

5. Physiotherapy, rehabilitation, and psychotherapy

6. Nerve blocks may be used for severe spasticity

7. Immunosuppressive drugs are being investigated

as treatment


Nursing Care of Clients with Multiple SclerosisA. Assessment

1. History of onset and progression of motor

and sensory lossand sensory loss

2. Factors that intensify symptoms



Nursing Care of Clients with Multiple SclerosisB. Planning/Implementation

1. Rest periods

2. Avoid hot baths

3. Use assistive devices3. Use assistive devices

4. Assist the client and family to plan and

implement a bowel and bladder regimen


Nursing Care of Clients with Multiple SclerosisB. Planning/Implementation

5. Allay anxiety

� NO false hopes during periods of remission

� Allow to ventilate feelings � Allow to ventilate feelings

� Seek counseling and rehabilitation

� Explain the disease to client and family

� Help the client reestablish a realistic self-image

� Teach the client to compensate for problems

with gait


Nursing Care of Clients with Multiple Sclerosis

6. Provide care to prevent decubiti and

contractures

a. Provide special skin care

b. Provide special attention to jointsb. Provide special attention to joints


SSCCLLEERR

pasm; slurred speech

ognitive loss

oss of bowel & bladder function

motional affect is inappropriate; eye problems

estRROOSSIISS


wallowing problems

est

ptic discs are pale

teroids

mpotence; increased DTR

Characteristics Multiple Sclerosis Myastenia Gravis Guillaine- BarreSyndrome

Weakness Weakness Weakness

Causes Demyelination of

the myelin sheath

inflammatory

disease of the CNS

A disease of the

“white matter”

Decrease in

functioning

acetylcholine

receptor site due to

antibodies

Inflammatory

disorder of the

peripheral nerves

with demyelination

SignificantHistory

May be

environmental

remissions may be

exacerbated by

stress, illness etc

No precipitating

factors

Precipitated by viral

or bacterial illness

approx. 2 weeks

before


Characteristics Multiple Sclerosis Myastenia Gravis Guillaine- Barre

Syndrome

Characteristics of weakness

No pattern,

assymetrical

Increase weakness

with prolong activity

Ascending, bilateral,

symmetrical

Diplopia Ataxia

Diplopia, ptosis,

Severe weakness

and numbness in Signs Numbness, tingling,

muscle weakness

and spasm, pain

Diplopia, ptosis,

dysphagia

and numbness in

arms and legs

characterize GBS

Epidemiology Female 20-40 Y/O

caucasian Female of

reproductive age


Characteristics Multiple Sclerosis Myastenia GravisGuillaine- Barre

Syndrome

Diagnostic Tools

EMG Tensilon Test EMG

Complications Respiratory distress

Contractures

Aspiration

Respiratory distress

Myasthenic

Cholinergic

Crisis

Respiratory distress

Contractures

Aspiration


BRAIN TUMORSBRAIN TUMORS

Brain Tumors

A. Etiology and pathophysiology

1. Either benign or malignant

2. Classified according to tissue of origin

a. Meningiomaa. Meningioma

b. Acoustic neuroma and optic nerve spongioblastoma

c. Gliomas: originate in neural tissue; usually malignant

(1)Astrocytoma

(2)Glioblastoma

(3)Oligodendroglioma

d.Hemangioblastomas and angiomas

e. Metastatic tumors


Brain TumorsB. Clinical findings

1. Subjective

a. Headache that increases with stooping

b. Lethargy

2. Objective

a. Vomiting

b. Papilledema (noted on ophthalmoscopy)

c. Abnormal brain waves on the EEG


Brain TumorsSymptoms may vary depending on location of

tumor

a. Frontal lobe

b. Temporal lobe

c. Parietal lobec. Parietal lobe

d. Occipital region

e. Cerebellar region

f. Signs of increased intracranial pressure

g. Motor and sensory deficits


Brain Tumors


1. Radiation therapy and/or chemotherapy

2. Surgery for partial or complete removal of the 2. Surgery for partial or complete removal of the

lesion

a. Craniotomy with removal of lesion and invaded tissue

b. Stereotaxic laser surgery; employs computer-directed

laser to eradicate tissue

3. Steroids, anticonvulsives, and osmotic diuretics to

control symptoms may be ordered


Nursing Care of Clientswith Brain TumorsA. Assessment

1. History from client and family to identify behavioral changes, coping skills, and behavioral changes, coping skills, and neurologic deficits


3. Signs of increased intracranial pressure


Nursing Care of Clientswith Brain TumorsC. Planning/Implementation

1. Provide emotional support

2.Maintain the client’s comfort 2.Maintain the client’s comfort

3.Support client's nutrition


Nursing Care of Clientswith Brain TumorsC. Planning/Implementation

4. Provide care for the client requiring brain

surgery

a. Obtain consent for surgery and removal of a. Obtain consent for surgery and removal of

hair After surgery keep the client's head

elevated 30 degrees (12 inches) to aid

drainage

b. Support respiratory function

c. Assess the client's level of consciousness and

neurologic status for changes


Nursing Care of Clientswith Brain Tumors

e. Observe for signs of increased intracranial pressure

(ICP)

(1) Decreased level of consciousness

(2)Restlessness

(3)Weakness or paralysis (3)Weakness or paralysis

(4)Visual and other sensory disturbances

(5) Increased systolic pressure; widening pulse

pressure

(6)Decreased pulse rate

(7)Changes in respiratory pattern

(8)Unilateral nonreactive and/or dilated pupil

progressing to bilateral


Nursing Care of Clientswith Brain Tumors

(9)Headache

(10)Rapid rise in body temperature

(11)Vomiting

(12)Seizures

(13)Papilledema(13)Papilledema

(14)Use strict aseptic technique with ICP monitoring

(15)Observe dressings for cerebrospinal spinal (CSF) leakage or hemorrhage

(16)Maintain accurate intake and output records

(17)Utilize hypothermia as ordered if the client is febrile; fever increases metabolic needs of the brain


EPILEPSYEPILEPSY(SEIZURE DISORDERS)(SEIZURE DISORDERS)

Epilepsy (Seizure Disorders)

A. Etiology and pathophysiology1. Abnormal discharge of electric impulses by the

nerve cells in the brain

2. Onset of idiopathic epilepsy generally before age 30

3. Other conditions associated with seizures include brain tumor, CVA, hypoglycemia, and head trauma



4.Types of seizuresa. Partial seizures (seizures beginning locally)

(1)Simple

(2)Complex

b. Generalized seizures (bilaterally symmetric and without local onset) (1)Absence (petit mal)

(2)Myoclonic

(3)Tonic-clonic (grand mal)

c. Status epilepticus


Seizure Disorders

Generalized seizures1. Grand mal seizure

2. Absence (petit mal)

• preceded by an aura

• tonic- clonic phases

• ends with postictal phase

• sudden vacant facial expression

• all motor activity ceases

3. Myoclonic Seizures • possible loss of muscle tone

• brief flexor muscle spasm: may have

arm extension, trunk flexion

• May be generalized or local

• occurs only when fever is rising

• Common to less than 5 years old


Seizure Disorders

Partial Seizures1. Simple Partial Seizure •Motor, sensory or autonomic

symptoms without loss of

consciousness

•Begins in focal area but 2. Complex partial seizure

•Begins in focal area but

progresses to grand mal

seizures

Status Epilepticus • Recurrent generalized

seizures without gaining

consciousness



B. Clinical findings (tonic-clonic seizures) 1. Subjective

a. Aura or warning sensation

b. Loss of consciousness during seizure

c. Lethargy often follows return to consciousness (postictal phase)

d. Dyspnea d. Dyspnea

2. Objective

a. Pupils become fixed and dilated

b. Often the client cries out as seizure begins or as air is exhaled forcefully

c. Tonic and clonic movement of the muscles

d. Incontinence

e. Abnormal EEG



C. Therapeutic interventions1. Anticonvulsant therapy continued throughout life

a. Phenytoin sodium (Dilantin), carbamazepine (Tegretol), valproic acid (Depakene), mephenytoin (Mesantoin) and primidone (Mysoline) often used to control tonic-clonic seizures

b. Trimethadione (Tridione), phensuximide (Milontin), and b. Trimethadione (Tridione), phensuximide (Milontin), and ethosuximide (Zarontin) to control absence seizures

c. Diazepam (Valium) given IV to treat status epilepticus

2. Sedatives (e.g., phenobarbital) used to reduce emotional stress

3. Neurosurgery is sometimes indicated if seizures are caused by tumors, abscesses, or vascular problems


NURSES NOTES

Therapeutic level of Dilantin: 10-20 mcg/ml

WOF: � Gingival hyperplasia� GI disturbances� Hepatotoxicity� Ataxia� Ataxia� Hypocalcemia� Decreased absorption of vitamin D

REMEMBER:

� GOOD ORAL HYGIENE

� REPORT TO MD IF Sx WORSENS


COUNSELLING

CALM

ANTI-CONVULSANTS

APNEA/CYANOSIS

EVALUATE CHANGES IN LOC

S

Phenobarbital (Sodium luminal), Primidone (Mysoline), Carbamazepine (Tegretol), Phenytoin (Dilantin)


SAFETY

AVOID ALCOHOL

ACTIVITIES?

R EDUCE STIMULI;

REMAIN WITH CLIENT

REORIENT

Nursing Care of Clients with EpilepsyA. Assessment

1. History of type, frequency, and duration of

seizures

2. History to identify precipitating factors

3. Sensations associated with the seizure that may

constitute an aura

4. Detailed list of client's medications


Nursing Care of Clients with EpilepsyB.Planning/Implementation

1. Provide protection for the client during and after the seizure

2. Help the client who can identify an aura2. Help the client who can identify an aura

3. Encourage the client to carry and wear a medical alert tag

4. Help the client plan a schedule


Nursing Care of Clients with Epilepsy

5. Instruct the client to refrain from excessive use of

alcohol

6. Teach the client and family to:6. Teach the client and family to:

� observe the aura

� initial point of seizure

� type of seizure

� level of consciousness

� loss of bladder and bowel control

� progression of seizure

� postictal condition


Nursing Care of Clients with Epilepsy

7. Encourage the client to express feelings.

8. Lifetime medication use

9. Teach client about anticonvulsant therapy


INCREASED INCREASED INTRACRANIAL INTRACRANIAL INTRACRANIAL INTRACRANIAL PRESSUREPRESSURE

INCREASED INTRACRANIAL PRESSURE

Monroe- Kellie Doctrine: An increase in the volume of any one of the components of the brain will lead to a change in the volume of the other components in order to maintain the ICP maintain the ICP

Condition associated with increased ICP:1. Mass Lesions

2. Head Injuries

3. Infections

4. Vascular Insult



• LOC changes

• Increasing systolic BP

• Headache

• Vomiting

Clinical Manifestations

• Increasing systolic BP

• Bradycardia

• Cheyne-Stokes breathing

• Fever

• Vomiting

• Anisocoria

• Papilledema

• Hemiplegia/hemiparesis



Laboratory Diagnostics� CT Scan

� MRI

Medical Management • Osmotic diuretics

• Loop diuretics � MRI

� Cerebral Angiography


• Loop diuretics

• Corticosteroids

• Barbiturates

• Surgery


Nursing Interventions

HOB elevated; Semi- Fowler’s

Evaluate and prevent increase of ICP Evaluate and prevent increase of ICP

Airway

Drainage; Drugs (e.g. mannitol)

Safety


CEREBROVASCULAR CEREBROVASCULAR ACCIDENT ACCIDENT ACCIDENT ACCIDENT

CEREBROVASCULAR ACCIDENT

� Either hemorrhagic or

ischemic in origin

� Men> women

Risk Factors

• Diabetes mellitus

• Cardiac disease

• Hypertension� Men> women

� TIAs are warning

signals!!!


• Hypertension

• Obesity

• Smoking

• Use of OCPs

• Stress

• Inactivity

Clinical Manifestations

1. Signs of increased

ICP

2. Cognitive deficits

� Short and long- term

memory recall

4. Communication loss

5. Apraxia

6. Agnosia

7. Visual-perceptual

dysfunction

� Homonymous � Altered judgment

3. Motor deficits

� Hemiplegia/

hemiparesis

� Dysarthria

� Dysphagia

� Homonymous

hemianopsia

� Diplopia

8. Sensory changes


Left Hemisphere Stroke

Right Hemisphere Stroke

Paralysis on the right

side

Paralysis on the left

side

Right visual field

defects

Left visual field

defects

Aphasia Spatial- perceptual

deficits

Altered intellectual

ability

Increased

distractibility

Slow, cautious

behavior

Impulsive behavior


Laboratory Diagnostics1. CT Scan/ MRI

2. Cerebral angiography

Medical Management

1. Hyperosmotic

agents

2. Corticosteroids


2. Corticosteroids

3. Anticonvulsants

4. Thrombolytics

5. Anticoagulants

6. Antihypertensives

Nursing Interventions:Acute Phase

� Maintain patent airway and adequate

ventilation

� Monitor VS, neuro checks and signs of � Monitor VS, neuro checks and signs of

increased ICP, shock and seizures

� Provide complete bedrest as ordered

� Maintain IV fluid and electrolyte balance and

ensure adequate hydration


Nursing Interventions:

Acute Phase

� Maintain proper body positioning

� Head of bed maybe elevated at least 30-45 degrees

� Turn and reposition patient every 2 hours on

unaffected side and 20 minutes on the affected side unaffected side and 20 minutes on the affected side

� Passive ROM every 4 hours

� Promote skin integrity

� Maintain adequate elimination

� Maintain a quite and restful environment

� Administer medications and monitor for side- effects



Rehabilitation Phase

Hemiplegia

� Turn every 2 hours

� Use footboards to prevent footdrop

� Support paralyzed arm with pillows or a sling prevent � Support paralyzed arm with pillows or a sling prevent

subluxation of shoulder

� Provide active and passive ROM every 4 hours

� Apply lotion over bony prominences

� Avoid too much drying and too much moisture in skin




Dysphagia

� Check gag reflex before feeding

� Offer soft foods

� Place food in unaffected side of mouth � Place food in unaffected side of mouth

� Have patient sit upright when eating and 30 minutes afterward

Homonymous hemianopsia

� Early in care, approach client on unaffected side

� Place personal belongings, food on unaffected side

� Teach client the technique of scanning




Receptive aphasia

� Give simple slow directions

� Use short, simple questions

� Use nonverbal communication techniques � Use nonverbal communication techniques

Expressive aphasia

� Allow sufficient time for patient to answer question

� Anticipate needs of patient


CEREBRAL CEREBRAL ANEURYSMANEURYSM

Cerebral Aneurysm

Etiology and pathophysiology

1. Sac formed by dilation of the walls of an artery within the cranial cavity

2. May be the result of a congenital weakness in the vessel, trauma, or arteriosclerosisarteriosclerosis

3. Symptoms occur when the aneurysm compresses nearby nerves or when it ruptures


Cerebral Aneurysm

Clinical findingsSubjective

a. Unilateral headache

b. Pain in the eye

c. Diplopiac. Diplopia

d. Tinnitus


Cerebral Aneurysm

Objective

a. Rigidity of the back of the neck and spine

b. Ptosis of the eyelid

c. Hemiparesisc. Hemiparesis

d. Decreased level of consciousness

e. Deviations from normal results in CT scan and lumbar puncture

f. Signs of increased ICP if rupture occurs


Cerebral Aneurysm


1. Attempt to keep the client hypotensive

2. Clips: If there is a stalk connecting the

aneurysm; cut off blood supply to the

aneurysm permanently


Nursing Care of Clients with Cerebral AneurysmsA. Assessment


2. Presence of signs of increased ICP


Nursing Care of Clients with Cerebral AneurysmsB. Planning/Implementation

1. Continue neurologic assessment

2. Assist with lumbar puncture

3. Teach client the need to continue antihypertensive medications

4. Teach client to avoid straining, lifting, exerting, and acutely flexing the neck


HEAD INJURYHEAD INJURY

Head InjuryTypes:

1. Concussion – results in temporary neurologic

dysfunction

2. Contusion – more severe blow that bruises the

brain

3. Hemorrhage

a. Epidural hematoma

b. Subdural hematoma

c. Subarachnoid hemorrhage

d. Intracerebral hemorrhage

4. Fractures


Head Injury

Clinical Manifestations:� Depends on the type of injury

� Signs of increased ICP

� Compound fractures:

Rhinorrhea − Rhinorrhea

− Otorrhea

− Raccoon’s sign

− Battle’s sign

− Conjunctival hemorrhage


Laboratory Diagnostics:• Skull X- ray

• CT Scan

Nursing Interventions:• Similar to care patients with increased ICP

• Care of patients with basal skull fracture

- Have patient lie in bed unless contraindicated


- Have patient lie in bed unless contraindicated

- Place a loose collection pad under the nose or over

the ear

- Caution patient not to blow the nose or sneeze

- Placing NGT is contraindicated

- Nasotracheal suctioning is contraindicated

� Observe for complication (e.g. meningitis)

CRANIOTOMYCRANIOTOMY

Craniotomy

Nursing Care1. Airway

� Position to side to prevent aspiration

� Vigorous coughing is contraindicated

2. Positioning 2. Positioning a. Supratentorial Surgery

� Avoid positioning on operated side if large tumor was removed

� Place on his side with HOB elevated at 45 degrees

b. Infratentorial Surgery � Keep patient flat; on either side with head aligned to

spinal column


3. Observe for signs of complications

(increased ICP, meningitis, seizures)

4. Monitor the incision site for signs of

infection

5. Provide pain medications for the headache

6. Nutrition 6. Nutrition

� Supratentorial: no contraindications

� Infratentorial: NPO for 24 hours post-op


Craniotomy

6. Avoid:� Suctioning nose if without written order

� Placing patient in T-berg position

� Flexing neck of patient � Flexing neck of patient

� Positioning on operated side if large tumor

was removed

� Take temperature orally

� Sedating heavily


MENINGITISMENINGITIS

Meningitis

A.Most common CNS infection of infants and children

B. Inflammation of the meninges by bacteria that travel via the cerebrospinal fluid

C. Classification: culture of cerebrospinal fluid used to help identify organism

1. Bacterial: caused by pus-forming bacteria

2. Tuberculous

3. Viral or aseptic


Meningitis

D. Clinical findings• Opisthotonos

• Headache

• Irritability and high-pitched cry

• Signs of increased intracranial pressure • Signs of increased intracranial pressure

• Fever, nausea, and vomiting

• Meningococcal meningitis: petechiae and purpuric skin rash

E. Therapeutic intervention - massive doses of intravenous antibiotics


Nursing Care of Patients with MeningitisA. Assessment

1. Fever

2. Headache, irritability

3. Vomiting

4. Seizures

5. Nuchal rigidity5. Nuchal rigidity

B. Analysis/Nursing Diagnoses1. Altered family processes related to having a child with a

serious illness

2. Risk for infection related to presence of infective organisms

3. Risk for injury related to presence of infection


Nursing Care of Patients with MeningitisC.Planning/Implementation

1. Provide for rest

2. Decrease stimuli from the environment

3. Position on the side with head gently supported in extensionextension

4. Institute respiratory isolation

5.Maintain fluid balance because of meningeal edemaa. Record intake and output carefully

b. Correct any deficits

c. Monitor IV fluid

d. Daily weights


Nursing Care of Patients with MeningitisC. Planning/Implementation

6. Provide emotional support for parents, since

child usually becomes ill suddenly

7. Administer antibiotic therapy as prescribed 7. Administer antibiotic therapy as prescribed

8. Observe for complications such as septic

shock and circulatory collapse


Meningitis Encephalitis Brain Abscess

Causative

Organisms

Bacteria, fungi,

yeasts, viruses

Bacteria, fungi,

yeast, viruses,

parasites

Bacteria

Clinical

Manifestations

• Nuchal rigidity

• (+) Brudzinski

• (+) Kernigs

• s/sx of increased

ICP

• Fever

• Mental

deterioration

• Amnesia

• Personality

changes

•Hemiparesis

S/sx of increased ICP

• Fever •Hemiparesis

Diagnostics • Stained smears and

sensitivity

• Lumbar puncture

• Viral studies • CT Scan, skull x-

ray

Medical

Management

Antibiotics with

sensitivity tests

Supportive

treatment vidarabine

Antibiotics Incision

and drainage


Meningitis

Predisposing Factors:

� Basilar skull fracture

� Brain/spinal surgery

� Sinus, upper respiratory or ear infections

Laboratory Diagnostics:

� Stained Smears and sensitivity

� Lumbar puncture

or ear infections

Clinical Manifestations:

� Nuchal rigidity � Kernig’s sign� Brudzinski sign� Fever

� Seizures

Medical Management:

� Antibiotics


INTRACRANIAL INFECTIONS

Nursing Management:

1. Assess level of consciousness, VS and neurologic

checks regularly

2. Minimize environmental stimulation 2. Minimize environmental stimulation

3. Have a family member at the bedside when possible

4. Administer sedatives and mild analgesics as indicated

5. Monitor and initiate seizures precautions

6. Monitor for residual side effects such as vision,

hearing, activity and cognitive processes


NEUROLOGIC DISORDERS

NIO C. NOVENO, RN, MAN, MSN

Microsoft Power Point Neuro Disorders

Education

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