MEDSURG 2 (LECTURE) PDF - Neurology Nursing

MEDSURG 2 (LECTURE) NCM 116 AUTOSOMAL DOMINANT MANAGEMENT OF PATIENTS WITH Cerebral arteriopathy Familial Alzheimer's disease...

MEDSURG 2 (LECTURE) NCM 116 AUTOSOMAL DOMINANT MANAGEMENT OF PATIENTS WITH Cerebral arteriopathy Familial Alzheimer's disease NEUROLOGICAL DYSFUNCTION Huntington's disease Myotonic dystrophies ASSESSMENT Neurofibromatosis Von Hippel-Lindau syndrome PAST HEATH, FAMILY, AND SOCIAL HISTORY The nurse may inquire about any family AUTOSOMAL RECESSIVE history of genetic diseases. Canavan disease A review of the medical history, including a Familial dysautonomia system-by-system evaluation, is part of Friedreich ataxia the health history. The nurse should be aware of any history of X-LINKED trauma or falls that may have involved the Duchenne muscular dystrophy head or spinal cord. Fragile X syndrome Questions regarding the use of alcohol, medications, and illicit drugs are also Inheritance pattern is not distinct; However, there relevant. is a genetic predisposition for the disease: The history-taking portion of the neurologic Amyotrophic Lateral Sclerosis assessment is critical and, in many cases Epilepsy of neurologic disease, leads to an accurate Neural tube defects (e.g., spina bifida, diagnosis. anencephaly) The nurse may inquire about any family Parkinson's disease history of genetic diseases. Tourette syndrome A review of the medical history, including a system-by-system evaluation, is part of Other genetic disorders that also impact the the health history. neurologic system: The nurse should be aware of any history of Bipolar disease trauma or falls that may have involved the Down syndrome head or spinal cord. Phenylketonuria (PKU) Questions regarding the use of alcohol, Schizophrenia medications, and illicit drugs are also Tay-Sachs disease relevant. Tuberous sclerosis complex The history-taking portion of the neurologic assessment is critical and, in many cases FAMILY HISTORY SPECIFIC TO NEUROLOGIC of neurologic disease, leads to an accurate DISORDERS diagnosis. Assess for other similarly affected relatives Several neurologic disorders are with neurologic impairment. associated with genetic abnormalities Inquire about age of onset neurologic impairment is noted with many (e.g., present at birth-spina bifida other genetic illnesses. developed in childhood-Duchenne muscular dystrophy 1 1 DLMB | NATIONAL UNIVERSITY - MANILA  MEDSURG 2 (LECTURE) NCM 116 developed in adulthood-Huntington NOCICEPTIVE PAIN disease, Alzheimer's disease, ALS). Transduction - activation of primary Inquire about the presence of related afferent nociceptors conditions such as intellectual disability or At the site of injury phospholipase breaks learning disabilities (neurofibromatosis down phospholipids into arachidonic acid type 1) → cyclooxygenase (COX) metabolizes arachidonic acid to PATIENT ASSESSMENT prostaglandins Assess for the presence of other physical COX-1: always present, protects GI COX-2: features suggestive of an underlying present in injuries, causes pain and genetic condition, such as skin lesions seen inflammation in neurofibromatosis (café-au-lait spots). NSAIDs blocks the COX to effect analgesia Assess attention span, and the presence of hyperactivity or withdrawn behavior. Transmission - action potentials are Assess for other congenital abnormalities transmitted along the nerve fibers: (e.g., cardiac, ocular). A-delta fibers Inspect for presence of freckles in the allow relatively quick localization of pain axillary or inguinal areas. releases glutamate which activates N- Assess for presence of uncoordinated methyl-D-aspartate (NMDA) movement of extremities, muscle twitching, or history of seizures C fibers Assess for poor or hyperactive muscle tone. produce poorly localized and often aching Assess for episodes of forgetfulness or or burning pain. uncharacteristic changes in behavior or mood. Perception - activation of higher brain Inspect for disproportionate facial features structures (fragile X or Down syndrome Awareness, emotions, and impulses Observe for presence of "tics" or associated with pain uncontrolled body movement. It can be targeted by nonpharmacologic Ask about history of seizures or head therapies, such as distraction. trauma Modulation - noxious stimuli are Common symptoms modulated at every level from the Pain periphery to the cortex and involves many Seizures different neurochemicals Headache Endorphins - endogenous opioids Dizziness and Vertigo Visual disturbances NEUROPATHIC PAIN Muscle weakness caused by either a lesion or a disease Abnormal sensation involving the somatosensory nervous system Peripheral mechanisms: 2 2 DLMB | NATIONAL UNIVERSITY - MANILA  MEDSURG 2 (LECTURE) NCM 116 Neuroplasticity - abnormal reorganization HEADACHES in the nervous system Peripheral sensitization - due to increased HEADACHE - PRIMARY TYPE INCLUDES: sodium channel activities → heightened Migraine - is a complex of symptoms excitability characterized by periodic and recurrent Allodynia - pain from normally non- attacks of severe headache lasting from noxious stimulus hours to days in adults. It is primarily a Hyperalgesia - increased pain response vascular disturbance that has a strong from minimally painful stimulus familial tendency. Maybe preceded by a visual aura. CENTRAL MECHANISMS Tension-type - lend to be chronic and less Central sensitization - abnormal severe and are probably the most hyperexcitability of central neurons in the common type of headache. The pain spinal cord usually radiates from the lower back of the Pain (inferred pathology: Nociceptive head, the neck, the eyes, or other muscle (Physiologic) vs Neuropathic groups in the body typically affecting both sides of the head Cluster headaches - NOCICEPTIVE NEUROPATHIC MIXED PAIN recurrent severe headaches on one side of PAIN PAIN the head, typically around the eye. There is PHYS Normal Abnormal Components often accompanying eye watering, nasal IOLO processi processing of of both congestion. or swelling around the eye on GIC ng of sensory input nociceptive the affected side. PRO stimuli by the and Headaches - recurrent severe headaches CESS that peripheral or neuropathic on one side of the head, typically around damage central pain; poorly the eye. There is often accompanying eye s tissues nervous defined watering, nasal congestion. or swelling or has system or around the eye on the affected side. the both Secondary headache potential A symptom associated with other causes, to do so such as a brain tumor, an aneurysm, or if lumbar puncture. prolonge Although most headaches do not indicate d; can be serious disease, persistent headaches somatic require further investigation. or visceral SEIZURES The result of abnormal electrical discharges in the cerebral cortex, which then manifest as an alteration in sensation, behavior, movement, perception, or consciousness. 3 3 DLMB | NATIONAL UNIVERSITY - MANILA  MEDSURG 2 (LECTURE) NCM 116 The alteration may be short, such as in a SYMPTOMS blank stare that lasts only a second, or of longer duration, such as a tonic-clonic Muscle weakness grand mal seizure that can last several A common manifestation of neurologic minutes. disease. The seizure activity reflects the area of the It frequently coexists with other symptoms brain affected. of disease and can affect a variety of Seizures can occur as isolated events, such muscles, causing a wide range of disability. as when induced by a high fever, alcohol or Weakness can be sudden and permanent, drug withdrawal, or hypoglycemia. as in stroke, or progressive, as in A seizure may also be the first obvious sign neuromuscular diseases such as of a brain lesion. amyotrophic lateral sclerosis. familial tendency. Maybe preceded by a visual aura. Abnormal Sensation Abnormal sensation is a neurologic DIZZINESS AND VERTIGO manifestation of both central and peripheral nervous system disease. Altered sensation can affect small or large An abnormal sensation of imbalance or areas of the body. It is frequently movement. associated with weakness or pain and is Patients use vague and varied descriptions potentially disabling Vertigo or the illusion of movement sensed Lack of sensation places a person at risk for as moving, usually as rotation. falls and injury. VISUAL DISTURBANCES Physical Assessment General Survey Normal vision depends on functioning Mental status visual pathways through the retina and Intellectual function optic chiasm and the radiations into the Thought content visual cortex in the occipital lobes. Lesions Emotional status of the eye itself (e.g., cataract), lesions Language ability along the pathway (e.g., tumor), or lesions Impact on lifestyle in the visual cortex (e.g., stroke) interfere Level of consciousness with normal visual acuity. Abnormalities of eye movement (as in the Examining the Motor System nystagmus associated with multiple sclerosis) can also compromise vision by Motor Ability causing diplopia or double vision. Assessment of muscle size and tone as well as strength coordination and balance. Patient is instructed to walk across the room. if possible while the examiner observes posture and gait. 4 4 DLMB | NATIONAL UNIVERSITY - MANILA  MEDSURG 2 (LECTURE) NCM 116 The muscles are inspected, and palpated, Temperature if necessary, for their size and symmetry. Vibration Note for atrophy or involuntary movements Position sense (proprioception). (tremors, ties) Tactile sensation is assessed by lightly Abnormalities in tone (spasticity, rigidity, touching a cotton wisp or fingertip to flaccidity) corresponding areas on each side of "e body. Muscle Strength o Sensitivity of proximal parts is 5-point scale: compared with that of the distal 5 = full power of contraction against gravity parts; the right and the left sides and resistance (normal) are compared. amount of resistance (slight weakness) Pain and temperature are transmitted 3 = just sufficient strength to overcome the together in the lateral part of the spinal force of gravity (moderate weakness) cord. Determining the patient's sensitivity (moderate weakness) to a sharp object can assess superficial 2 = ability to move but not to overcome the pain perception. force of gravity (severe weakness) Vibration and proprioception are (severe weakness) transmitted together in the posterior part 1 = minimal contractile power (contraction of the spinal cord. Vibration may be can be palpated but no movement is evaluated through the use of low noted) frequency (128 or 256 Hz) tuning fork. Position sense or proprioception. may be Muscle Coordination determined by asking the patient to close Run the heel down the anterior surface of both eyes and indicate, as the great toe or the tibia of the other leg. index finger is alternately moved up and ATAXIA - incoordination of voluntary down, in which direction movement has muscle action, particularly of the muscle taken place. groups used in activities such as walking or Vibration and position sense are often lost reaching for objects. together, frequently in circumstances in TREMORS - rhythmic, involuntary which all other sensation remains intact. movements noted at rest or during movement. Tests for integration of sensation in the brain: Romberg test - screening test for balance 2-point discrimination - if only one site is Cerebellar tests: reported, the one not being recognized is o Alternating pronation/supination of said to demonstrate extinction the hands Tactile identification - identify objects by o Heel-to-toe walking (forward and hand. backward) AGNOSIA - inability to identify objects or sounds Examining the Sensory System Tests for Tactile sensation Superficial pain 5 5 DLMB | NATIONAL UNIVERSITY - MANILA  MEDSURG 2 (LECTURE) NCM 116 Primitive reflexes - reappearance signify TYPES OF AFFECTED progressive NS degeneration AGNOSIA CEREBRAL AREA o Suck VISUAL OCCIPITAL LOBE o Snout AUDITORY TEMPORAL LOBE o Palmar grasp TACTILE PARIETAL LOBE o Palmomental BODY PARTS PARTIETAL LOBE AND GLASGOW COMA SCALE RELATIONSHIPS EXAMINING REFLEXES Deep tendon reflexes Ratings 0 no response 1+ Diminished (hypoactive) 2+ Normal 3+ Increased (maybe normal) 4+ Hyperactive Or present, diminished, absent Techniques for eliciting major reflexes. Eliciting the biceps reflex. Eliciting the triceps reflex. Eliciting the patellar reflex. Eliciting the Achilles reflex. DIAGNOSTICS Superficial Reflexes COMPUTED TOMOGRAPHY SCANNING Corneal Computed tomography (CT) scanning Palpebral uses a narrow X-ray beam to scan body Gag parts in successive layers. Upper/lower abdomen The images provide cross-sectional views Cremasteric (male) of the grain, distinguishing differences in Perianal tissue densities of the skull, cortex, subcortical structures, end ventricles. Pathologic reflexes An intravenous (IV) contrast agent (usually Babinski sign - defect in the corticospinal iodine-based) may be used to highlight tract differences further. o Dorsiflexion of the big toe and fanning of the small toes 6 6 DLMB | NATIONAL UNIVERSITY - MANILA  MEDSURG 2 (LECTURE) NCM 116 The image is displayed on an oscilloscope Ferromagnetic substances 'h the body may or television monitor and it's photographed become dislodged by the magnet so and stored digitally. history of working with metal fragments The patient lie with head held perfectly still must be reviewed to avoid distortion of the image Screen for any type of cardiac implantable NURSING INTERVENTIONS electronic device. Essential nursing interventions include Access for implants containing metal. preparation for the procedure and patient Cochlear implants will be inactivated by monitoring. MRI. Preparation includes educating the patient All metal objects and cards read magnetic about the need to lie quietly throughout the strips must not be brought into the room. procedure. A review of relaxation techniques may be CEREBRAL ANGIOGRAPHY helpful for patients with claustrophobia. Cerebral angiography is an x-ray study of Sedation can be used if agitation, the cerebral radiation with a contrast restlessness, or confusion interferes with a agent injected into a selected artery. successful study. Cerebral angiograms are performed by If a contrast agent is used access for threading a catheter through the femoral iodine/shellfish allergy. artery in the groin or the radial artery of the Kidney function must also be evaluated wrist and up to the desired vessel. A suitable IV line for contrast injection in a period of fasting (usually 4 hours are NURSING INTERVENTIONS required prior to the study Prior to the angiography, the patient’s Fluid intake is also encouraged after IV blood urea nitrogen and creatinine should contrast to facilitate clearance through the be checked to ensure the kidneys will hu kidney. able to excrete the contrast agent. The patient should be well hydrated, and MAGNETIC RESONANCE IMAGING clear liquids are usually permitted up to the MRI use this powerful magnetic field to time of the lest. obtain images of different areas of the The patient is instructed to void body. immediately before the test, and locations The magnetic field causes the hydrogen of the appropriate peripheral pulses are nuclei (protons) within the body to align like marked with a felt-tip pen. small magnets in a magnetic field. In The patient is instructed to remain combination with radiofrequency pulses, immobile during the angiogram process the protons emit signals, which are and is told to expect a brief feeling of converted to images. warmth in the face, behind the eyes, or in the jaw, teeth, tongue, and lips, and a NURSING INTERVENTIONS metallic taste when the contrast agent is Patient preparation includes providing injected. education and obtaining an adequate When the femoral artery is selected for history. access, the hair in the groin is clipped and prepared and a local anesthetic agent is 7 7 DLMB | NATIONAL UNIVERSITY - MANILA  MEDSURG 2 (LECTURE) NCM 116 given to minimize pain at the insertion site Used as screening tool prior to invasive and to reduce arterial spasm. procedures. A catheter is introduced into the femoral artery, flushed with heparinized saline, and ELECTROENCEPHALOGRAPHY (EEG) filled with contrast agent. An electroencephalogram (EEG, represents Fluoroscopy is used to guide the catheter to c.10%0 of the electrical activity generated in the appropriate vessels. the brain. Post procedure monitoring includes It is obtained through electrodes applied observation of the injection site for on the scalp or through microelectrodes bleeding or hematoma formation placed "thin the bipin tissue. Monitor peripheral pulses doctor mark prior It provides an assessment of cerebral to the test. electrical activity. For signs of possible embolism such as It is useful for diagnosing and evaluating discoloration and changes in temperature. seizure disorders, coma, or organic brain syndrome. MYELOGRAPHY Tumors, brain abscesses, blood clots, and A myelogram is an X-ray of the spinal infection may cause abnormal patterns in subarachnoid injection of a contrast agent electrical activity. into the spinal subarachnoid space The EEG is also used in making a through a lumbar puncture. determination of brain death. It shows any distortion. of the spine, cord or spinal dural SAC caused by tumors, cysts, NURSING INTERVENTIONS herniated vertebral discs, or other lesions. Patient education. EEG: o Is diagnostic not curative NURSING INTERVENTIONS o Takes about 45 - 60 mint as long Patient education. o Does not cause electric shock Post procedure, patient is advised to Sleep may be deprived the night prior to remain in bed (4 10 24 hours) with the head the test. of the bed elevated ad 30 to 15) Brain medications should be withheld 24 to Drinking liberal amounts of fluid for 48 hours prior to the test. rehydration may decrease the incidence of Stimulating food, such as coffee and soda, post lumbar puncture headache. should be omitted from the meal. Monitor vital signs and patient's ability to Fasting is avoided to prevent altered blood void glucose level. NONINVASIVE CAROTID FLOW STUDIES LUMBAR PUNCTURE AND EXAMINATION OF THE Noninvasive carotid flow studies use CSF ultrasound imagery and Doppler A lumbar puncture (spinal tap) is carried measurements of arterial blood to out by inserting a needle into the lumbar evaluate carotid and deep circulation. subarachnoid space to withdraw CSF. The graph produced indices blood velocity. o The spinal cord ends at the level of Increased blood velocity can indicate the 1st lumbar vertebra, insertion of stenosis or partial obstruction the needle below the level of the 8 8 DLMB | NATIONAL UNIVERSITY - MANILA  MEDSURG 2 (LECTURE) NCM 116 second lumbar vertebra prevents PATHOLOGICAL CHANGES – PATIENTS puncture of the spinal cord WITH NEUROLOGICAL DYSFUNCTION The test may be performed to. obtain CSF for examination, to measure and reduce CSF pressure, to determine the presence or ALTERED LEVEL OF CONCIOUSNESS absence of blood in the CSF, and to administer medications intrathecally (into Altered LOC is present when the patient is the spinal canal). not oriented, does not follow commands, or needs persistent stimuli to achieve a state NORMAL CSF FINDINGS: of alertness. Clear and colorless appearance -turbid Alterations in LOC occur along a cloudy means cellular debris continuum, and the clinical manifestations Protein = 15 to 45 mg/d - higher levels nay depend on where the patient is on this indicate a tumor or an infection continuum. Glucose = 45 to 75 mg/ml - higher levels integrate the presence of an infection, Alert Drowsy Obtunded/Lethargic Stuporous leukemia or cancer Semi comatose RBC = zero - presence means bleeding WBC = 0.8/ul - increase level means Alert – Oriented, opens eyes spontaneously, infection response appropriately Lethargic – Sleepy; Slow to respond but NURSING INTERVENTIONS responds appropriately: Oriented, Opens eyes Lumbar puncture may be risky in the in response to verbal stimuli. presence of an intracranial mass lesion Stuporous - Aroused only in response to Removal of CS can decrease intraspinal painful stimuli; Never fully awake; conversation, pressure that may cause the brain to if present, is confused or unclear, opens eye to herniate. painful stimuli. The nurse may be asked to assist in Semi comatose - May move in response to positioning the patient. painful stimuli; Does not converse; protective Monitor for post lumbar puncture blink, swallowing, and people reflexes are headache. present. Other complications include temporary Comatose - Unresponsive except through voiding problems, slight elevation of severe pain; Protective reflexes are absent; temperature, backache or spasm, and Pupils are a fixed; No voluntary movement. stiffness of the neck. Akinetic mutism is a state of unresponsiveness to the environment in which the patient makes no voluntary movement. Persistent vegetative state is a condition in which the patient who is unresponsive resumes sleep-wake cycles after coma but 9 9 DLMB | NATIONAL UNIVERSITY - MANILA  MEDSURG 2 (LECTURE) NCM 116 is devoid of cognitive or affective mental function. Locked-in syndrome results from a lesion affecting the pons and results in paralysis and the inability to speak, but vertical eye movements and lid elevation remain intact and are used to indicate responsiveness. Altered LOC is not a disorder itself; rather, it is a result of multiple pathophysiologic phenomena. The cause may be o Neurologic (head injury, stroke) o Toxicologic (drug overdose, alcohol intoxication) o Metabolic (hepatic or kidney injury, diabetic ketoacidosis) The underlying cause of neurologic dysfunction is disruption in the cells of the nervous system, neurotransmitters, or brain anatomy. o Disruptions result from cellular edema or other mechanisms, such as disruption of chemical transmission at receptor sites by antibodies. The most severe neurologic impairment results in flaccidity. Posturing may be decorticate or decerebrate. Decerebrate is more severe. MEDICAL MANAGEMENT First priority of treatment: obtain and maintain a patent airway. Manage secretions; positioning may not be adequate Intubation or tracheostomy may be performed Mechanical ventilation is used to maintain adequate oxygenation and ventilation Circulatory status is monitored IV line is inserted 10 10 DLMB | NATIONAL UNIVERSITY - MANILA  MEDSURG 2 (LECTURE) NCM 116 NURSING MANAGEMENT: DIAGNOSES achievement of intact oral mucous Impaired breathing due to neurologic membranes, maintenance of normal skin impairment integrity, absence of corneal injury. Risk for injury associated with lack of attainment of effective thermoregulation, adaptive and defensive resources due to and effective urinary elimination. decreased LOC Additional goals include bowel Risk for hypovolemia associated with continence, restoration of health inability to take fluids by mouth maintenance. Risk for impaired nutritional intake Maintenance of intact family or support associated with inability to ingest system, and absence of complications. nutrients to meet metabolic needs Impaired oral mucous membrane INCREASED INTRACRANIAL PRESSURE integrity associated with mouth breathing, absence of pharyngeal reflex, The rigid cranial vault contains brain and altered fluid intake tissue (1400 g), blood (75 mL), and CSF (75 Risk for impaired skin integrity associated mL). The volume and pressure of these with prolonged immobility three components are usually in a state of Risk for injury associated with restraints equilibrium and produce the ICP. Risk for injury associated with diminished ICP is usually measured in the lateral or absent corneal reflex ventricles, with the normal pressure being Impaired thermoregulation associated O to 10 mm Hg, and 15 mm Hg being the with damage to hypothalamic center upper limit of normal. Impaired urination associated with Monro-Kellie Hypothesis/Doctrine: altered impairment in neurologic sensing o Brain Tissue and control o blood circulation Bowel incontinence associated with o CSF volume impairment in neurologic sensing and Because brain tissue has limited space to control and also associated with changes expand, compensation typically is in nutritional delivery methods accomplished by Impaired health maintenance associated - displacing or shifting CSF with neurologic impairment - increasing the absorption or Interrupted family process associated diminishing the production of CSF*, or with health crisis - decreasing cerebral blood volume. Increased ICP > 20 mm Hg NURSING MANAGEMENT: PLANNING Affects many patients with acute The patient with altered LOC is subject to neurologic conditions because all of the complications associated with pathologic conditions alter the immobility. relationship between intracranial volume GOALS: and ICP. normalization of breathing. Elevated ICP is most commonly protection from injury, attainment of fluid associated with head injury volume balance, maintenance of Other causes - Space-Occupying Lesions nutritional needs. (SOL): 11 11 DLMB | NATIONAL UNIVERSITY - MANILA  MEDSURG 2 (LECTURE) NCM 116 brain tumors CEREBRAL RESPONSE TO INCREASED ICP: subarachnoid hemorrhage The brain can maintain a steady toxic and viral encephalopathies perfusion pressure if the arterial systolic blood pressure is 50 to 150 mm Hg and the ICP is less than 40 mm Hg. The Cerebral Perfusion Pressure (CPP) is calculated by subtracting the ICP from the mean arterial pressure (MAP). If, MAP = Systole + Diastole/2 = 100; and ICP = 15, then the CPP = 85 mm Hg Normal CPP = 70 - 100 mm Hg CPP < 50 mm Hg causes irreversible neurologic damage If CPP = MAP, cerebral circulation stops CUSHING'S RESPONSE During brain ischemia, the vasomotor Increased ICP from any cause decreases center triggers an increase in arterial cerebral perfusion, stimulates further pressure in an effort to overcome the edema (swelling and may shift brain increased ICP. tissue, resulting herniation —a dire and Results in increase in the systolic blood frequently fatal event. pressure with a widening of the pulse pressure and cardiac slowing DECREASED CEREBRAL BLOOD FLOW At this point, herniation of the brain stem The vasomotor centers are stimulated, and occlusion of the cerebral blood flow and the systemic pressure rises to occur. maintain cerebral blood flow. Usually, this is accompanied by a slow bounding pulse CUSHING'S TRIAD: and respiratory irregularities. Bradycardia An increase in the partial pressure of Hypertension arterial carbon dioxide (PaCO,) causes Bradypnea cerebral vasodilation. Decreased venous outflow may also MEDICAL MANAGEMENT increase cerebral blood volume. Increased ICP is a true emergency Invasive monitoring of ICP CEREBRAL EDEMA Relieve increased ICP by: Activation of compensatory mechanisms; Decreasing cerebral edema - steroids AUTOREGULATION - the brain's ability to and osmotic diuretics, restrict fluids change the diameter of the blood vessels Lowering the volume of CSF - carbonic Reduction of CS production anhydrase (Acetazolamide), surgical drainage (ventriculostomy) 12 12 DLMB | NATIONAL UNIVERSITY - MANILA  MEDSURG 2 (LECTURE) NCM 116 Reducing cellular metabolic demand - controlling fever, maintaining systemic blood pressure and oxygenation NURSING MANAGEMENT: ASSESSMENT Because the patient is critically ill, ongoing assessment is more focused, including pupil checks, assessment of selected cranial nerves, frequent measurements of vital signs and ICP, and the use of the Glasgow Coma Scale. NURSING MANAGEMENT: DIAGNOSIS Impaired breathing associated with neurologic dysfunction (brain stem compression, structural displacement) SEIZURE DISORDERS Risk for ineffective tissue perfusion associated with the effects of increased Seizures are episodes of abnormal motor, ICP sensory, autonomy, or psychic activity (or Hypovolemia associated with fluid a combination of these) that result from restriction sudden excessive discharge from Risk for infection associated with ICP cerebral neurons. monitoring system (fiberoptic or Associated loss of consciousness, excess intraventricular catheter) movement or loss of muscle tone or movement, and disturbances of behavior, mood, sensation, and perception. The specific causes of seizures are varied and can be categorized as genetic, due to a structural or metabolic condition, or the cause may be yet unknown etiologies: o Head injury o Hypertension o Hypoxemia of any cause, including vascular insufficiency o Metabolic and toxic conditions (e.g., kidney injury, hyponatremia, hypocalcemia, hypoglycemia, pesticide exposure) o Allergies o Brain tumor o Cerebrovascular disease o CNS Infection 13 13 DLMB | NATIONAL UNIVERSITY - MANILA  MEDSURG 2 (LECTURE) NCM 116 o Drug and alcohol withdrawal o Awareness o Fever (childhood) o Aware o Impaired awareness o Unknown awareness TYPES OF SEIZURE DISORDERS GENERALIZED ONSET Occur in and rapidly engage bilaterally Seizures are episodes of abnormal motor, distributed networks. Often involve both sensory, autonomy, or psychic activity (or hemispheres of the brain a combination of these) that result from Motor - intense rigidity of the entire body sudden excessive discharge from may occur (generalized tonic), followed cerebral neurons. by alternating muscle relaxation and Associated loss of consciousness, excess contraction (clonic). movement or loss of muscle tone or o The simultaneous contractions of movement, and disturbances of behavior, the diaphragm and chest muscles mood, sensation, and perception. may produce a characteristic The specific causes of seizures are varied epileptic cry or shrill. and can be categorized as genetic, due to o Patient can be incontinent of urine a structural or metabolic condition, or the and feces. cause may be yet unknown etiologies: o At post-ictal, patient relaxes and o Head injury lies in deep coma, breathing o Hypertension noisily (abdominal), or maybe o Hypoxemia of any cause, including awake but confused vascular insufficiency o Metabolic and toxic conditions Typical Absence (petit mal) (e.g., kidney injury, hyponatremia, o Occurs in children but rarely hypocalcemia, hypoglycemia, extend into adolescence pesticide exposure) o Manifest as staring blankly, o Allergies conscious but detached o Brain tumor o Make completely cease or develop o Cerebrovascular disease into another type of seizure o CNS Infection o Drug and alcohol withdrawal UNKNOWN ONSET o Fever (childhood) When the beginning of a seizure is not known, it’s now called an unknown onset FOCAL (OR PARTIAL) ONSET seizure. A seizure could also be called an o originate within a localized area of the unknown onset if it’s not witnessed or seen brain. by anyone, for example when seizures o Motor - only a finger or hand may shake, happen at night or in a person who lives or mouth jerk uncontrollably alone. o Nonmotor - may talk unintelligibly, As more information is learned, an unusual or unpleasant sights, sounds, unknown onset seizure may later be odors, or taste 14 14 DLMB | NATIONAL UNIVERSITY - MANILA  MEDSURG 2 (LECTURE) NCM 116 diagnosed as a focal or generalized STATUS EPILEPTICUS seizure. o (acute prolonged seizure activity) can be EPILEPSY defined as a seizure lasting 5 minutes or o is a group of syndromes characterized by longer or serial seizures occurring without unprovoked, recurring seizures. full recovery of consciousness between o Epileptic syndromes are classified by attacks. specific patterns of clinical features, o The term has been broadened to include including age at onset, family history, and continuous clinical or electrical seizures seizure type. (on EEG) lasting at least 30 minutes, even o Epilepsy can be primary (idiopathic) or without impairment of consciousness. secondary (when the cause is known and o It is considered a medical emergency. the epilepsy is a symptom of another o Status epilepticus produces cumulative underlying condition, such as a brain effects. Vigorous muscular contractions tumor). impose a heavy metabolic demand and o Epilepsy is not synonymous with can interfere with respirations. Some intellectual or developmental disabilities. respiratory arrest at the height of each o But many people who have these seizure produces venous congestion and types of disabilities, because of hypoxia of the brain. Repeated episodes serious neurologic damage, also of cerebral anoxia and edema may lead have epilepsy. to irreversible and fatal brain damage. o Factors that precipitate status epilepticus o IN WOMEN include interruption of anticonvulsant o note an increase in seizure medication, fever, concurrent infection, or frequency during menses. other illness. o Effectiveness of contraceptives is decreased by anticonvulsant MEDICAL MANAGEMENT medications. Alternative method o The management of epilepsy is should be offered. individualized to meet the needs of each o Congenital fetal anomaly is 2 to 3 patient and not just to manage and times higher in women with prevent seizures. epilepsy o Management differs from patient to o Patients with epilepsy, particularly those patient, because some forms of epilepsy with generalized events that are arise from brain damage and others medically refractory, are at a serious risk result from altered brain chemistry. for Sudden Unexpected Death In Epilepsy o Medication therapy controls seizure. They (SUDEP), defined as non traumatic, non- are selected on the basis of the type of drowning unexpected death of a patient seizure being treated and the with epilepsy effectiveness and safety of the medication. o Surgery is indicated for patients whose epilepsy results from intracranial tumor, abscesses, cysts, or vascular anomalies. 15 15 DLMB | NATIONAL UNIVERSITY - MANILA  MEDSURG 2 (LECTURE) NCM 116 Broken teeth and injury to the lips and tongue may result from such an action. o Do not attempt to restrain the patient during the seizure, because muscular contractions are strong, and restraint can produce injury. o If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions. Prevent Injury: Nursing Care After a Seizure o Keep the patient on one side to prevent NURSING MANAGEMENT: DIAGNOSIS aspiration. Make sure the airway is patent. o Risk for injury associated with seizure o On awakening, reorient the patient to the activity environment. o Fear associated with the possibility of o If the patient is confused or wandering, seizures guide the patient gently to a bed or chair. o Difficulty coping associated with stresses o If the patient becomes agitated after a imposed by epilepsy seizure (postictal), stay a distance away, o Lack of knowledge associated with but close enough to prevent injury until epilepsy and anticonvulsant medications the patient is fully aware. NURSING INTERVENTIONS Prevent Injury: Nursing Care During a Seizure o Provide privacy and protect the patient from curious onlookers. (The patient who has an aura may have time to seek a safe, private place.) o Ease the patient to the floor, if possible. o Protect the head with a pad to prevent injury (from striking a hard surface). o Loosen constrictive clothing and remove eyeglasses. o Push aside any furniture that may injure the patient during the seizure. o If the patient is in bed, remove pillows and raise side rails. o Do not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything in the mouth during a seizure. 16 16 DLMB | NATIONAL UNIVERSITY - MANILA  MEDSURG 2 (LECTURE) NCM 116 CLINICAL MANIFESTATIONS: ALZHEIMER’S DISEASE (AD) In early disease there is forgetfulness and subtle memory loss, although social skills and behavioral patterns remain intact. ALZHEIMER Forgetfulness is manifested in many daily a progressive, irreversible, degenerative actions with progression of the disease (eg, neurologic disease that begins insidiously the patient gets lost in a familiar and is characterized by gradual losses of environment or repeats the same stories). cognitive function and disturbances in Conversation becomes difficult, and word- behavior and affect. finding difficulties occur. not a normal part of aging. Ability to formulate concepts and think complex brain disorder caused by a abstractly disappears. combination of various factors that may Patient may exhibit inappropriate include: impulsive behavior. o genetics Personality changes are evident; patient o neurotransmitter changes may become depressed, suspicious, o vascular abnormalities paranoid, hostile, and combative. o stress hormones Speaking skills deteriorate to nonsense o circadian changes syllables; agitation and physical activity o head trauma increase. o the presence of seizure disorders. Voracious appetite may develop from high Two types: activity level; dysphagia is noted with o FAMILIAL or Early-Onset (rare) disease progression. o SPORADIC or Late-Onset (90%) Eventually patient requires help with all aspects of daily living, including toileting PATHOLOGICAL CHANGES because incontinence occurs Amyloid plaques: A buildup of beta- Terminal stage may last for months or amyloid (AB) proteins outside of neurons years. Neurofibrillary tangles: A buildup of tau proteins inside neurons ASSESSMENT & DIAGNOSTIC FINDINGS Loss of neurons: A loss of neurons, Diagnosis by exclusion but can be made in especially in the basal forebrain and 90% of cases. neocortex Diagnosis is confined at autopsy. Synapse loss: A loss of connections Functional abilities assessment (e.g. Mini- between neurons mental Status Examination) Gliosis: A response from glial cells Electroencephalography (EEG) Computed tomography (CT) scan Magnetic resonance imaging (MRI) Laboratory tests (complete blood cell count, chemistry profile, and vitamin B12 and thyroid hormone levels) and examination of the cerebrospinal fluid (CSF) 17 17 DLMB | NATIONAL UNIVERSITY - MANILA  MEDSURG 2 (LECTURE) NCM 116 MEDICAL MANAGEMENT Deficient self-care, bathing/hygiene, Without a cure or a way to slow progression feeding, toileting related to cognitive of AD, treatment relies on managing decline cognitive symptoms: Impaired social interaction related to o Cholinesterase inhibitors, such as cognitive decline Donepezil hydrochloride (Aricept), Deficient knowledge of family/caregiver Rivastigmine. related to care for patient as cognitive o Tartrate (Exelon), Galantamine function declines hydrobromide (Razadyne [formerly Ineffective family processes related to known as Reminyl]), and Tacrine decline in patient’s cognitive function (Cognex). o These drugs enhance acetylcholine PLANNING AND GOALS uptake in the brain to maintain Goals for the patient may include memory skills for a period of time. supporting cognitive function, physical o Donepezil and the newest safety, reduced anxiety and agitation, medication Memantine (Namenda) adequate nutrition, improved can be used for management of communication, activity tolerance, self- moderate to severe AD symptoms. care, socialization, and support and education of caregivers. NURSING PROCESS: THE PATIENT WITH Supporting Cognitive Function ALZHEIMER’S DISEASE Provide a calm, predictable environment to minimize confusion and disorientation. ASSESSMENT. Help patient feel a sense of security with a Obtain health history with mental status quiet, pleasant manner; clear, simple examination and physical examination, explanations; and use of memory aids and noting symptoms indicating dementia. cues. Report findings to physician. As indicated, assist with diagnostic evaluation, NURSING INTERVENTIONS promoting calm environment to maximize Promoting physical safety patient safety and cooperation. provide a safe environment(whether at home or in the hospital) to allow patient to NURSING DIAGNOSES move about as freely as possible and Impaired thought processes related to relieve family’s worry about safety. decline in cognitive function And false and other accidents by removing Risk for injury related to decline in cognitive obvious hazards and providing adequate function lighting; install handrails in the home. Anxiety related to confused thought Prohibit driving. processes Allow smoking only with supervision. Imbalanced nutrition: less than body Reduce wandering behavior with gentle requirements related to cognitive decline persuasion and destruction. Supervise all Activity intolerance related to imbalance in activities outside the home to protect activity/rest pattern patient. As needed, secure doors leading 18 18 DLMB | NATIONAL UNIVERSITY - MANILA  MEDSURG 2 (LECTURE) NCM 116 from house. Ensure that patient wears an Encourage spouse to talk about any sexual identification bracelet or neck chain. concerns and suggest sexual counseling if Avoid restraints because they may necessary. increase agitation. Promoting adequate nutrition Promoting independence in self-care activities keep mealtimes simple and calm; avoid simplify daily activities into short confrontations. achievable steps so that patient feels a Cut food into small pieces to prevent sense of accomplishment. choking and convert liquids to gelatin to Maintain patient's personal dignity and ease swallowing. Offer one dish at a time. autonomy. Prevent burns by serving typically hot food Encourage patient to make choices when and beverages warm. appropriate and to participate in self-care activities as much as possible. Balancing activity and rest Offer music, warm milk, or a back rub to Reducing anxiety and agitation help patient relax and fall asleep. provide emotional support to reinforce a To enhance night-time sleep, provide positive self-image. sufficient opportunities for daytime When skill losses occur adjust goals to fit exercise. Discourage long periods of patients declining ability and structure daytime sleeping. activities to help prevent agitation. Assess and address any unmet underlying Keep the environment simple, familiar, and physical or psychological needs that may noise-free; limit changes. prompt wandering or other inappropriate Remain calm and unhurried, particularly if behavior. the patient is experiencing a combative, agitated state known as catastrophic Supporting home- and community-based care reaction (over reaction to excessive be sensitive to the highly emotional issues stimulation). that the family is confronting. Notify the local adult Protective Services Improving communication agency if neglect or abuse is suspected. reduce noises and distractions. Refer family to Alzheimer's Association for Use easy to understand sentences to assistance with family support groups, convey messages. respite care, and adult day care services. Providing for socialization and intimacy needs EVALUATION encourage visits, letters, and phone calls Expected patient outcomes (visits should be brief and non stressful, Patient maintains cognitive, functional, and with one or two visitors at a time). social interaction abilities for as long as Encourage patient to participate in simple possible. activities or hobbies. Patient remains free of injury. Advise that the nonjudgmental friendliness Patient participates in self-care activities of a pet can provide satisfying activity and as much as possible. an outlet for energy. 19 19 DLMB | NATIONAL UNIVERSITY - MANILA  MEDSURG 2 (LECTURE) NCM 116 Patient demonstrates minimal anxiety and agitation. Patient can communicate (verbally or nonverbally). Patient’s socialization and intimacy needs are met. Patient receives adequate nutrition, activity, and rest. Patient and family caregivers are knowledgeable about condition and treatment and care regimens. 20 20 DLMB | NATIONAL UNIVERSITY - MANILA