14 - Neurodegenerative Disorders.pdf

Basic Medical-Surgical Nursing Care of the Patient with Neurologic Disorders 1  Patient Assessment (Recognizing Cues) Patient/family history Presenting complaint Physical/mental Psychosocial/lifestyle Age...

Basic Medical-Surgical Nursing Care of the Patient with Neurologic Disorders 1  Patient Assessment (Recognizing Cues) Patient/family history Presenting complaint Physical/mental Psychosocial/lifestyle Age (p.830, 10th ed.) (p.870, 11th ed.) acute neuro change – due to diabetes? are they hypoxic occupation – patient working? presenting complaint – numbiness, speech, etc physical and mental – LOC? are they able to do normal ADLs? can they talk about their health on their own psychosocial – what they do and how it affects them age – memory loss 2  Diagnostic Studies: Imaging ct scan – quick, easy ○ shows swelling xray – looks at bone, checking for fractures MRI ○ no metal allowed ○ takes 10-20 min ○ uses magnets for very detailed picture ○ can explicitly show brain tumor MRA ○ magnetic resonance angiography ○ very detailed pic of vessels ○ uses contrast ○ avoid metformin 3  Diagnostic Studies: Labs Blood Complete metabolic panel (CMP), CBC Electrolytes Glucose (hypoglycemia) Serology Drug levels Drug screen Cerebrospinal Fluid (CSF) hypoxia, hypoglycemia – can cause acute neuro changes CMP – H/H, for bleeds (like neuro bleeds) electrolytes – cause cardiac dysrhytmias, are there any imbalances? glucose – hypoglycemia causing neuro changes? serology – looks for infections (COVID, flu, etc) drug levels – medication history (for trough levels) drug screens – opioids, cocaine → sudden increase in BP CSF – there’s should be any protein, bacteria or blood in CSF 4  Diagnostic tests Electromyography (EMG) Electroencephalography (EEG) EMG – picture of the muscle waveform produced ○ shows decrease in amplitude EEG – could be continuous or one time ○ determines if patient is having seizure ○ educate pt not to touch electrodes ○ 12-24 h – hold stimulant or sedative meds before procedure ○ make sure pt eats, to prevent hypoglycemia 5  less conduction – decreased conduction rate auditory – watches nerves and how fast they work visual – checks optic nerve evoked potentials – testing that we can see hear, feel somatosensory – tests what we can feel 6  Lumbar Puncture Insertion of spinal needle into the subarachnoid space between the 3rd & 4th lumbar vertebrae. Reasons for LP CSF should be clear & colorless Nursing Considerations Pre Post-procedure measure the pressure and contents that come out expected CSF – clear, colorless preop – check skin prior, looking for infection postop – headaches are normal ○ check bandaid for drainage or CSF leak csf leak – fixed with blood patch or surgical repair ○ bedrest 4-6 hours 7 8  Transcranial Dopplers Ultrasound for cerebral circulation Cerebral vasospasm or narrowing of arteries May be used as an alternative to Cerebral Angiography for subarachnoid hemorrhage detection cerebral angiography – more invasive  Autoimmune/Degenerative Disorders: Goals Maintain quality of life Goals of care Curative treatment? Manage symptoms Help patient be independent as long as possible Support families as roles change recognizing changes and keeping patients at baseline they came in ○ prevent worsening manage s/s – provide meds that can help s/s 10  Autoimmune: Multiple Sclerosis (MS) Etiology Demyelination of myelin sheath in CNS. Results in nerve impulses being either blocked or slowed. damage of myelin sheath can affects any part of the body MS – treated with immunosuppresants or immunomodulators 11  Signs & Symptoms: MS Key Features, p.873 Remissions & exacerbations Visual changes Tremors Weakness Fatigue Paresthesia Ataxia (gait, fine motor) Dysarthria, Dysphagia Bowel & bladder dysfunction Cognitive changes Memory impairment teach patients when s/s start – report for tx immediately acute decrease in function; with treatment s/s go away can aspirate due to dysphagia uncoordinated gait = ataxia ○ risk for falls trouble speaking – dysarthria, dysphagia bowel and bladder dysfunction – nerves not working memory impairment – late sign of MS baclofen – commonly used for MS ○ used for chronic pain 12  Psychosocial Concerns : MS Length of diagnosis Misdiagnosis "You just need some sleep" Upon diagnosis: Relief vs anger/frustration After diagnosis: Anxiety, depression Promote open communication/therapeutic communication Assess for coping mechanisms and stress management Sexual dysfunction nonspecific disease often tired, fatigued constantly misdiagnosed bc of how nonspecific it is promote open communication – talk about their feelings and offer resources, or therapy assess for coping mechanisms – do they have family support less libido seen more in young female adults 14  MS Interventions(Responding): Disease Modifying Therapy Baclofen, Docusate No cure Meds to treat SX Sodium Frequent assessment Physical & of liver & bone Medical marijuana occupational therapy marrow function Use of disease-modifying Education drugs (DMD) Let’s look at the med sheet prevent and manage s/s most meds are hepatotoxic marijuana – helps with pain myelosuppression – suppression of bone marrow ○ monitor RBCs teach about meds, what to look out for and what to avoid 15  Diagnostic Tests for MS MRI Presence of IgG & ↑ WBC in CSF Elevated IgG in serum Evoked potential testing there’s no golden standard bc its so nonspecific white plaque – shows signs of possible multiple sclerosis blood work is important to see elevated IgG in serum evoked potential testing – mostly just assessing damage at this point 16  Disease Modifying Drugs: Immunomodulators Immunomodulators: Adjusts the immune response interferon beta-1a (Avonex) IM/SQ dimethyl fumarate (Tecfidera) Mechanism of action glatiramer acetate (Copaxon) natalizumab (Tysabri) fingolimod (Gilenya) teriflunomide (Aubagio) Headaches Side effects GI distress (constipation) Fatigue Infections Liver damage Potential adverse effects Bone marrow suppression Anaphylaxis Severe tissue injury Treatment should continue indefinitely. No live vaccines Nursing considerations Assess for s/s of hepatotoxicity. Assess for s/s of bone marrow impairment Lehne (11th), p. 216-19 Assess for hypersensitivity **Immunomodulators: Adjusts the immune response suppresses infection monitor for anaphylaxis no live vaccines due to risk for infection must be vaccinated 3-4 weeks before starting INDEFINITE treatment 17 18 19 20 21  Disease Modifying Drugs: Immunsuppressants Immunosuppressants: Suppress the immune response Mechanism of action mitoxantrone (Novantrone) GI distress (nausea, vomiting, diarrhea) Side effects Hair loss Blue-green color to skin, sclera, urine Infections Bone marrow suppression Anaphylaxis Potential adverse effects Cardiotoxicity Fetal Harm Severe tissue injury Treatment should continue indefinitely. No live vaccines Assess for s/s of bone marrow impairment Assess for hypersensitivity Nursing considerations If extravasation occurs, discontinue infusion and restart in another IV site. Lehne (11th), p. 225-27 Patient should not be pregnant. Pregnant RNs should be careful with handling. chemotherapy drug chronic MS treatment – to prevent worsening of symptoms adverse effects fetal harm – monitor before each dose for pregnancy can become necrotic if there is IV infiltration should continue INDEFINITELY 22  Treatment of MS exacerbation Glucocorticoid IVIG- IV Immunoglobulin Short course (3-5 days) of high-dose IV glucocorticoid for acute changes, NOT chronic for only 3-5 days of high dose IV for immunosuppressant IVIG-IV immunoglobulin – for flu-like s/s 23  methylprednisolone (Solumedrol) Regulates production of proteins leading to Mechanism of action immunosuppressive and anti-inflammatory processes. Weight gain Side effects GI Distress (N/V) Dizziness Osteoporosis Hyperglycemia Potential adverse effects Infection Cushing's Syndrome Assess for hyperglycemia Assess for s/s of infection May impair wound healing; monitor Nursing considerations wounds closely. May cause fluid retention; monitor weights as necessary Lehne (11th), p. 853 24  Treatment of Common MS Symptoms Urinary Retention Muscle Spasms (spasticity) Alpha Adrenergic Muscle Relaxers blocking agents Baclofen (Lioresal) o Tamsulosin (Flomax) o Terazosin (Hytrin) Constipation Pull it forward! Stool Softeners If we have a patient with o Docusate Sodium MS experience _____, what (Colace) might we order? o Polyethylene glycol o Nausea/vomiting (Miralax) o Sexual dysfunction (Erectile o Bisacodyl (Dulcolax) dysfunction) ****memorize adverse effects, side effects, how they work baclofen is testable**** patient with nausea/vomiting – order zofran, phenergan sexual dysfunction – sildenafil  Parkinson's Disease (PD) Progressive neurodegenerative disorder. Death usually occurs secondary to pulmonary or renal disease. neuromuscular and cognitive issues considered unsafe disease death usually occurs after pulmonary or renal disease 26  Pathophysiology of PD Depletion of dopamine, the neurotransmitter required to control posture & voluntary movement. Causes loss of control of voluntary movement Remember: Dopamine: required for relaxation of muscles Acetylcholine: required to contract muscles depletion of dopamine memorize – dopamine needed for muscle relaxation acetylcholine – needed to contract muscles 27  Signs & Symptoms: PD Characterized by 4 cardinal symptoms: Tremor Muscle rigidity Bradykinesia or Akinesia Postural instability muscle weakness masklike appearance of face drooling Impaired judgment & emotional instability Change in cognition, psychosis (late) ***memorize to understand meds having 2 or more of symptoms equals a parkinson’s diagnosis tremors – huge symptom bradykinesia – slow/low movement akinesia – late stage, patient is unable to move great risk for falls 28  Signs & Symptoms: PD Pill rolling Shuffling gait hunchback, slumped posture shuffling feet 29  PD Diagnosis No specific diagnostic tests Dopamine transporter scan (newer) - radioactive agent binds to dopamine transporter CSF may show ↓ dopamine levels. Single-photon emission computed tomography (SPECT), may show loss of dopamine-producing neurons. Presentation of symptoms: 2 http://www.ajnr.org/content/36/2/229 or more no specific diagnostic tests CSF – may show drop of dopamine levels parkinson's diagnosis = 2 or more symptoms 30  Medications for Treatment/Responding PD Let’s look at the neuro med sheet 31  Dopamine Replacement Drugs Lehne (11th), p. 191 Mechanism of action Increase the amount of dopamine available in the body Names levodopa/carbidopa (Sinemet) Nausea and Vomiting Side effects Darkened urine and sweat Dyskinesias Potential adverse effects Postural hypotension (orthostatic) Psychosis Educate patient on long term use and dyskinesias More effective than dopamine agonists Nursing considerations Preferred for improving motor function Educate that urine/sweat color change are normal and due to medication carbidopa – helps levodopa work better dyskinesias – disorders of movement psychosis – related to overdosing of dopamine replacement drug urine/swear color change are due to medicine = normal higher dose = could cause psychosis dopamine – helps control their movement ○ most effective 32  Dopamine Agonists Mechanism of action Directly activates dopamine receptors Lehne (11th), p. 191 Names bromocriptine (Parlodel) Nausea Dizziness Side effects Constipation Weakness Hallucinations Potential adverse effects Daytime sleepiness Postural hypotension (orthostatic) Can be used by itself or in conjunction with levodopa. If patient concerned with drug-induced dyskinesias, dopamine Nursing considerations agonists preferred. Typically given to younger patients who tolerate it better. act like dopamine not good for older adults postural hypotension orthostatic – adverse effect of this can be used in addition to OR instead of carbidopa/levodopa 33  Supplemental Meds for PD Monoamine oxidase-B (MAOB) Inhibitors Inhibits breakdown of dopamine selegiline (Eldepryl) rasagiline (Azilect) Catechol-O-Methyltransfera ses (COMT) Inhibitors Inhibits the breakdown of Levodopa by COMT entacapone (Comtan) tolcapone (Tasmar) protects levodopa that changes into dopamine 34  Drug Tolerance Efficacy may wear off over time May choose to: o Reduce drug dosage o Change drug to another o "Drug Holiday" Monitor patient symptoms during "drug holiday" o Worsening safety issues, risk of aspiration, worsening cognition, etc. Educate patient to report signs of worsening PD symptoms drug holiday – helps restore function it is has worn off ○ taken off for 7-10 days, then restart meds 1st, if it doesn’t work then brain surgery  Treatments/Responding for PD Deep Brain Stimulation Stereotactic Pallidotomy surgeries – implant electrodes into brain treatments to stimulate dopamine release deep brain stimulation – used for late stage of Parkinson’s disease ○ very invasive procedures stereotactic pallidotomy – creates lesions that interrupt overactive nerve signal to reduce PD symptoms (globus pallidus) 36