Chronic Neuro Lecture 2 PDF
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Beal University
Rayan Al Dabbah
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This document is a lecture on chronic neurological problems, specifically focusing on seizure disorders and epilepsy. It details the causes, clinical manifestations, diagnostics, complications, and management strategies. The lecture includes information on generalized and focal seizures. Furthermore, it covers nursing management and important considerations for seizure care.
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NSG 5130: Level III Nursing Theory Med-Surg Week 11: Chronic Neurological Problems Rayan Al Dabbah, RN, MScN Seizure Disorders and Epilepsy Seizures Seizure: “Transient, uncontrolled electrical discharge of neurons in the brain that interrupts normal function”. (Lewis, et. al., 2019, p.1...
NSG 5130: Level III Nursing Theory Med-Surg Week 11: Chronic Neurological Problems Rayan Al Dabbah, RN, MScN Seizure Disorders and Epilepsy Seizures Seizure: “Transient, uncontrolled electrical discharge of neurons in the brain that interrupts normal function”. (Lewis, et. al., 2019, p.1539) Often symptom of underlying illness Epilepsy May accompany other disorders or occur spontaneously without apparent cause Febrile seizures in infants/children Severe electrolyte imbalances (hyper & hyponatremia, hypocalcemia, hypophosphatemia) Hypoglycemia Infection (Lewis et. al., 2019 Epilepsy Abnormal neurons undergo spontaneous firing Cause of abnormal firing is unclear Structural, chemical, physiological or combo Firing spreads to adjacent or distant areas of the brain Site of electrical disturbance dictates if seizures will be generalized or partial A person must have at least 2 spontaneous seizures >24hrs apart to be diagnosed with epilepsy 75-85% of those diagnosed before age of 18 (McMillan, 2020) Causes Common causes during first 6 months of life Severe birth injury, Congenital birth defects involving CNS, Infections (febrile seizure >38), metabolic errors Common causes from ages 2 to 20 Infection (febrile seizure >38), Trauma, Genetics Common causes between ages 20 and 30 Structural lesions, Trauma, Brain tumor, Vascular disease Common causes after 50 Cerebrovascular lesions, Metastatic brain tumors 70% of seizure disorders are considered idiopathic (McMillan, 2020) Clinical Manifestations: Depends on where the seizure is located Three major categories: Generalized Focal Unknown Then divided by motor or non-motor presentation Several possible phases: 1. Prodrome phase 2. Aural phase (sensory warning) 3. Ictal phase (seizure event) 4. Postictal phase (after seizure recovery) (Lewis et. al., 2019 Generalized Seizures Generalized Seizures Affects entire brain so loss of consciousness for seconds to minutes is common Tonic-clonic (most common) Tonic phase – stiffening of the body (10-20 seconds) clonic phase – jerking of extremities (30-40 seconds) With or without cyanosis, salivation, tongue or cheek biting, incontinence Followed by postictal phase Muscle soreness, tired ++, takes time to feel “normal” (Lewis et. al., 2019 Generalized Seizures Absent seizures Typical Children - brief staring spell, can occur up to 100x/day if not diagnosed and treated Triggered by hyperventilation or flashing lights Atypical Children - brief staring spells + peculiar behavior during seizure, or confusion post seizure Myoclonic Sudden, excessive jerking (can be seen in palliative care r/t multiple meds for symptom management) Atonic (drop attach) – sudden falling to ground (Lewis et. al., 2019 Focal Seizures (Partial Seizures) Localized brain involvement (vs. total) Location coincides with specific behaviors/manifestations of seizures May start as partial but advance to tonic-clonic Ex: when aura is present Simple partial seizures Simple sensory or motor involvement No loss of consciousness, rarely last >1 minute (Lewis et. al., 2019 Focal Seizures (Partial Seizures) Complex partial seizures Involve alterations in LOC (unlike simple partial) Tends to affect temporal lobe Sound and speech Accounts for manifestations of confusion Often present as psychomotor seizures Lip-smacking or repetitive movements No memory of seizure activity Psychosensory symptoms that may occur during complex partial seizures include: Distortions of visual or auditory sensations, Vertigo, Alterations in memory & thought processes (McMillan, 2020) Seizure: Diagnostics Most useful: description of seizure and patient’s history EEG (electroencephalography) At point of care or overnight monitoring with video Rule out metabolic issues Bloodwork (sodium), urine test & liver/kidney tests (Lewis et. al., 2019 Seizures: Complications Physical Psychosocial Airway obstruction, impaired Limitations on lifestyle oxygen exchange (driving restrictions, Injury employment options) Falls, head trauma, burns, etc. (can be Social stigma fatal) Side effects from medications Depression, anxiety diplopia, drowsiness, ataxia, and mental slowing skin (rashes), gingiva (hyperplasia), bone marrow (blood dyscrasias), liver, and kidneys Status Epilepticus (Lewis et. al., 2019 Status Epilepticus State of continuous seizure activity in which seizures recur in rapid succession without return to consciousness between seizures. EMERGENCY Can lead to permanent brain damage Can involve any type op seizure: Tonic-Clonic most dangerous Management: Administer lorazepam (Ativan) and diazepam (Valium) (short acting) Followed by as phenytoin (Dilantin) or phenobarbital (long acting) Intubation and mechanical ventilation may be required (Lewis et. al., 2019, p. 1541 Seizures: Clinical Management Goals: Prevent injury Optimal mental and physical functioning while taking anticonvulsant medications Satisfactory psychosocial functioning CAUTION: Seizure: Drug Therapy Herbal remedies may interact with anti- convulsant Anti-seizure medications meds Seizure control, not a cure Anti-seizure meds work by: Stabilizing nerve cell membranes to prevent spontaneous/disorganized firing Phenytoin (Dilantin), Keppra, Phenobarbitol, Topamax, Valproic acid Start with one drug, then alter dose, then add another agent Monitoring of therapeutic blood levels may be necessary Monitor for LOC side effects Dizziness, drowsiness, headache, fatigue, sleep disturbances Lorazepam (Ativan) used for status epilepticus (McMillan, 2020) Ketogenic Diet? High fat, low carbohydrate diet Ketones replace glucose as energy source in the brain Do your own research! Lewis et. al., 2019) Seizures: Nursing Management Health Promotion Wearing helmets Proper diet, exercise, sleep Identify triggering event Avoid: Excessive alcohol, fatigue, loss of sleep Home Care: Make up missed does within 24 hours Teach emergency management Only call 911 if first seizure, 2 consecutive seizures, extensive injury (Lewis et. al., 2019 Seizure Care – Ictal Phase Record details about the seizure (timing, description) Maintain patent airway Side lying, tongue out Protect patient’s head, loosen tight clothing Do not restrain NOTHING IN MOUTH Be prepared to administer medications as per physician order Status epilectus management may be required (Lewis et. al., 2019 Seizure Care – Postical Phase Inform her that she just experienced a seizure. Suctioning, and oxygen may be needed Assessment: Vital signs LOC Assess for any weakness and paralysis Assess for the presence of any injuries. Provide information about how and (Lewis et. al., 2019 What is epilepsy? A Ma yo Clinic expert explain s (youtube.com) Which action would the nurse take first when caring for a client who is admitted to the emergency department after experiencing a seizure? The nurse is preparing to admit a patient who has been treated for status epilepticus in the emergency department. Which of the following equipment should the nurse have available in the room? A. Wrist restraints B. Tongue blade C. Suction tubing Correct D. Nasogastric tube The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. Which of the following actions is priority for the nurse to take initially? A. Assess the patient for a possible head injury. Correct B. Give the scheduled dose of divalproex. C. Document the timing and description of the seizure. D. Notify the patient’s health care provider about the seizure. Which of the following prescribed interventions will the nurse implement first for a hospitalized patient who is experiencing continuous tonic–clonic seizures? A. Give phenytoin 100 mg IV. B. Monitor level of consciousness. C. Obtain computed tomography scan. D. Administer lorazepam 4 mg IV. Correct A patient has a tonic–clonic seizure while the nurse is in the patient’s room. Which of the following actions should the nurse take? A. Insert an oral airway during the seizure to maintain a patent airway. B. Restrain the patient’s arms and legs to prevent injury during the seizure. C. Avoid touching the patient to prevent further nervous system stimulation. D. Time and observe and record the details of the seizure and An elementary teacher who has just been diagnosed with epilepsy after having a generalized tonic–clonic seizure tells the nurse, “I cannot teach anymore, it will be too upsetting if I have a seizure at work.” Which of the following responses by the nurse is best? A. “You may want to contact the Epilepsy Foundation for assistance.” B. “You might benefit from some psychological counselling at this time.” C. “The Department of Vocational Rehabilitation can help with work retraining.” D. “Half of all patients with epilepsy are well controlled with antiseizure drugs.” Which action will the nurse take when evaluating a patient who is taking phenytoin for adverse effects of the medication? A. Inspect the oral mucosa. Correct B. Listen to the lung sounds. C. Auscultate the bowel tones. D. Check pupil reaction to light. A patient who was noted to have a generalized seizure reports afterward that the seizure was preceded by numbness and tingling of the arm. What type of seizure would this be classified as? A. Atonic B. Partial Correct C. Absence D. Myoclonic A registered nurse (RN) must assess the body temperature of a client with a history of epilepsy. Which site for measuring temperature is contraindicated in this client? A- Skin B-Oral C-Tempanic D- Rectal Multiple Sclerosis (MS) MS Chronic, progressive, degenerative, autoimmune disorder of the CNS The immune system attacks myelin (protective covering of the nerves) in the brain, spinal cord, and optic nerves, which disrupts communication between the CNS and the rest of the body. There is currently no cure for MS, but treatments are available to decrease the frequency and severity of relapses and to ease MS symptoms. Canada has one of the highest rates of MS in the world (Government of Canada, 2019) MS: Pathophysiology Initial phases: myelin sheaths of the neurons in the brain and spinal cord are attacked, but the nerve fiber is not affected. Noticeable impairment of function, but myelin regenerates and symptoms disappear Disease progression: myelin is replaced by scar tissue forms hard, sclerotic plaque. Nerve impulses slow down without myelin + destruction of axons impulses totally blocked = Fig. 61-3. Pathogenesis of multiple sclerosis. A, Normal nerve cell with myelin sheath. permanent loss of function. B, Normal axon. C, Myelin breakdown. D, Myelin totally disrupted; axon not functioning. MS: Clinical Manifestations Vague symptoms occur intermittently over months and years Disease may not be diagnosed until long after onset of the first symptom. General symptoms characterized by Chronic, progressive deterioration in some Remissions and exacerbations in others Common signs and symptoms include Motor problems Sensory problems Cerebellar problems Cognitive problems Emotional problems (McMillan, 2020) MS: Complications Average life expectancy after onset of symptoms is more than 25 years MS deaths usually occur because of: infective complications (pneumonia) Complications related to immobility Unrelated to MS disease MS: Diagnostics Based primarily on history, clinical manifestations, and presence of multiple lesions over time measured by MRI Cerebral spinal fluid (CSF) analysis via a lumbar puncture ↑ in # of immunoglobulin G (IgG) Contains higher numbers of lymphocytes and monocytes MS: Clinical Management Drug Therapy Corticosteroids Treat acute exacerbations by reducing edema and inflammation at the site of demyelination. Do not affect the ultimate outcome or degree of residual neurological impairment from exacerbation Immunomodulators Mediate autoimmune processes that destroy myelin Immunosuppressive therapy Beneficial effects in patients in multiple stages of progressive and relapsing MS Immunosuppression has to be weighed very carefully (McMillan, 2020) MS: Clinical Management Collaborative Care Physiotherapy Relieve spasticity, improves coordination Train patient to substitute unaffected muscles for impaired muscles Water therapy Speech therapy Nutritional Therapy Include megavitamins and diets consisting of low-fat, gluten-free food High-protein diet with supplementary vitamins is often prescribed. (Lewis et. al., 2019 MS: Nursing Management Prevent major complications Avoid triggers (infection, trauma, stress) Impaired physical mobility Maximize neuromuscular function. Maintain independence in activities of daily living for as long as possible. Avoiding fatigue, extremes of hot and cold, exposure to infection Self-care deficit Assistive devices, self-catheterizations Risk for impaired skin integrity Good balance of exercise and rest & nutrition (McMillan, 2020) MS: Nursing Management Impaired urinary and bowel elimination pattern Teach self-catheterization if necessary Utilization of cholinergic drugs to improve bladder tone Teach adequate intake of fiber to aid in regular bowel habits Sexual dysfunction Support family processes Interrupted family processes Optimize psychosocial well-being Adjust to the illness. Assist patient in dealing with anxiety caused by diagnosis (McMillan, 2020) Mayo Clinic Explains Multiple Sclerosis (youtube.com) The nurse is obtaining a health history and physical assessment from a patient with possible multiple sclerosis (MS). Which of the following assessments should the nurse include? A. Assess for the presence of chest pain. B. Inquire about any urinary tract problems. Correct C. Inspect the skin for rashes or discoloration. D. Question the patient about any increase in libido. A female patient who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which of the following responses by the nurse is accurate? A. “MS symptoms may be worse after the pregnancy.” Correct B. “Women with MS frequently have premature labour.” C. “Symptoms of MS are likely to become worse during pregnancy.” D. “MS is associated with a slightly increased risk for congenital defects.” The nurse is caring for a patient with multiple sclerosis (MS) who has urinary retention caused by a flaccid bladder. Which of the following actions should the nurse plan to take? A. Teach the patient how to perform self-catheterization. Correct B. Decrease the patient’s fluid intake in the evening. C. Suggest the use of incontinence briefs for nighttime use only. D. Assist the patient to the commode every 2 hours during the day. Parkinson’s Disease (PD) PD “Progressive, neurodegenerative disease of the CNS (basal ganglia)” (Lewis et. al., 2019, p. 1552) Diagnosis increases with age, with peak onset in the seventh decade. Symptoms do not appear until 80% of neurons are damaged/lost More common in men, ratio of 3:2 Well established genetic component Pathologic process of PD involves degeneration of dopamine-producing neurons in the midbrain. (Lewis et. al., 2019 PD Disrupts dopamine-acetylcholine balance in basal ganglia (loss of dopamine, so actions of acetylcholine are stronger) Dopamine responsible for: Inhibiting NT: Posture, support, voluntary motion Acetylcholine responsible for: Excitatory NT This imbalances explains all symptoms (McMillan, 2020) Understanding Parkinson's disease (youtube.com) PD: Clinical Manifestations Triad Bradykines Tremor Rigidity Onset is gradual and ia insidious Beginning stages may involve only mild tremor, slight limp, or ↓ arm increased swing decrease decrease Later stages may have effect of in in shuffling, propulsive gait acetylcholi dopamine dopamine with arms flexed, and loss ne of postural reflexes (McMillan, 2020) Bradykinesia Rigidity Slowing down in Increased resistance initiation and execution to passive motion of movement when limbs are moved through ROM Loss of autonomic movements: blinking, sustained muscle swinging of arms while contraction, causes walking, swallowing of pain & stiffness saliva jerky quality when the Tremor joint is moved More prominent at rest Aggravated by emotional stress or ↑ concentration Described as pill rolling PD: Complications As disease progresses, complications increase Motor symptoms – loss of motor control Weakness Swallowing problems - aspiration risk, malnutrition Sleep disturbances/disorders Neurological problems Neuropsychiatric problems Dementia occurs in 20% of patients Greater risk for UTIs, pneumonia, skin breakdown Greater risk for orthostatic hypotension = risk for falls Most common cardiovascular autonomic dysfunction in Parkinson's patients R/t disease process and PD meds (Fereshtehnejad & Tökk, 2014) Non-motor symptoms Depression, anxiety, apathy, fatigue, pain (McMillan, 2020) PD: Diagnostics No specific test Rely on symptoms, clinical features, history PD = at least 2/3 of the classic triad manifestations Diagnosis confirmed if patient responds to drug therapy (Lewis et. al., 2019 PD: Clinical Management Drug Therapy Aimed at correcting imbalances of neurotransmitters (dopamine & acetylcholine) within the CNS Antiparkinsonian drugs either 1. Enhance or release supply of Dopamine (called dopaminergic drugs) (Levodopa + carbidopa) 2. Antagonize or block the effects of overactive cholinergic neurons (anticholinergics) Works on acetylcholine imbalance to treat tremors Medications must cross the blood brain barrier (McMillan, 2020) PD: Clinical Management Collaborative Care: Nutritional therapy Food should be cut into bite-sized pieces. Provide ample time to avoid frustration. Levodopa can be impaired by protein and B6 ingestion (plan to avoid high protein food items at closest associated meal) Promote physical exercise and a well-balanced diet. Limit the consequences from decreased mobility Specific exercises to strengthen muscles involved with speaking and swallowing Prioritize interventions based on patients report of most troublesome symptoms (Lewis et. al., 2019 Risk for Falls Create a space you’re familiar with Remove rugs, arrange power cords and add night lights Avoid multi-tasking while walking. Make the bathtub safer by adding mats with a grip or a grab bar Take your time standing up. (Michael J. Fox Foundation for Parkinson’s Research, 20 Lewis, et. al., 2019, p. 155 A patient with Parkinson’s disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which of the following actions should the nurse include in the plan of care? A. Instruct the patient in activities that can be done while lying or sitting. B. Suggest that the patient rock from side to side to initiate leg movement. Correct C. Have the patient take small steps in a straight line directly in front of the feet. D. Teach the patient to keep the feet in contact with the floor and slide them forward. The nurse assesses a patient in the health clinic who has symptoms of a stooped posture, shuffling gait, and pill rolling-type tremor. Which of the following prescriptions would the nurse anticipate? A. Oral corticosteroids B. Antiparkinsonian drugs Correct C. Electroencephalogram (EEG) testing D. Magnetic resonance imaging (MRI) he partner of a patient with Parkinson’s disease (PD) is upset and asks the nurse why he is no longer able to read the affectionate notes that the patient writes for him. Which of the following information is the basis for the nurse’s response? A. Characteristic slow speech makes it difficult for the patient with PD to put his/her thoughts on paper. B. Cogwheel rigidity makes it hard for the patient to hold a pen. C. Micrographia is common in patients with PD. Correct D. Depression often seen in PD leads to denying affectionate feelings. Which of the following information about a patient who is being treated with carbidopa/levodopa for Parkinson’s disease is most important for the nurse to report to the health care provider? A. Shuffling gait B. Tremor at rest C. Cogwheel rigidity of limbs D. Uncontrolled head movement Correct The nurse is caring for a patient with Parkinson’s disease who has decreased tongue mobility and an inability to move the facial muscles. Which of the following nursing diagnoses is of highest priority? A. Activity intolerance related to immobility B. Toileting self-care deficit related to impaired mobility C. Ineffective health management related to difficulty managing complex treatment regimen D. Imbalanced nutrition: less than body requirements related to insufficient dietary intake Correct The nurse is teaching a patient with Parkinson’s disease the preventive measures to reduce the risk of a fall. Which of the following instructions should the nurse include in the teaching session? A- Point the toes downward when stepping. B-Take two steps backward and three steps forward. C-Rock from front to back when walking. D-Drop rice kernels and step over them. Correct The nurse is caring for a patient with Parkinson’s disease who is admitted to the hospital for treatment of an acute infection. Which of the following nursing interventions will be included in the plan of care? A. Implement a bladder training schedule with a commode at the bedside. B. Observe for sudden exacerbation of symptoms. C. Provide high protein foods at each meal. D. Place an arm chair at the patient’s bedside. Correct Neurological Disorder Quick Review Neurological Disorders Quick Review, Parkinson's, MS, M G, ALS NCLEX RN & LPN (youtube.com) Myasthenia Gravis (MG) Myasthenia gravis - causes, symptoms, treatment, path ology (youtube.com) ALS Amyotrophic lateral sclerosis (ALS) | Lou Gehrig's diseas e | Symptoms, pathophysiology & management (youtub e.com) Guillain Barre Syndrome Guillain-Barré Syndrome (GBS) | Causes, Pathophysiolog y, Signs & Symptoms, Diagnosis, Treatment (youtube.co m)