Chapter 63 Chronic Neurologic Problems PDF

**Chapter 63** **Chronic Neurologic Problems** **KEY POINTS** HEADACHES - The 3 primary classifications of *headaches* include tension type, migraine, and cluster headaches. - *Tension-type headaches* occur bilaterally and have a pressing, tightening quality. They are usually of mil...

**Chapter 63** **Chronic Neurologic Problems** **KEY POINTS** HEADACHES - The 3 primary classifications of *headaches* include tension type, migraine, and cluster headaches. - *Tension-type headaches* occur bilaterally and have a pressing, tightening quality. They are usually of mild or moderate intensity. - *Migraine headaches* are recurrent. They are characterized by unilateral or bilateral throbbing pain. Premonitory symptoms and an aura may precede the headache. - *Cluster headaches* are a form of headache with a severe, sharp stabbing pain. They can occur repeatedly for weeks to months at a time, followed by periods of remission. - Drug therapies include: - Treatment for tension-type headaches includes aspirin, acetaminophen, or an NSAID alone or in combination with a sedative, muscle relaxant, or caffeine. - Migraine therapies include triptans, NSAIDs, aspirin, and caffeine-containing analgesics. Triptans work best when taken at the start of the headache. Some patients are on preventive treatment. - Triptans are the standard treatment for occasional cluster headache. Many patients receive preventative therapy with high-dose verapamil. - Adjunctive therapies used in the treatment of all headaches include meditation, yoga, biofeedback, cognitive-behavioral therapy, and relaxation training. ***Other Types of Headaches*** - A headache can accompany many other illnesses, including brain tumors, stroke, polycythemia vera, and diseases of the eyes, nose, and teeth. - Because of this variety, a thorough evaluation of any headache is needed. SEIZURE DISORDER {#seizure-disorder.ListParagraph} ================ - *Seizure disorder*, often called epilepsy, is a group of neurological diseases marked by recurring seizures, with neurobiologic, cognitive, psychologic, and social consequences. - A *seizure* is a transient, uncontrolled electrical discharge of neurons in the brain that interrupts normal function. Seizures may accompany a number of disorders. - Seizures are divided into 2 major classes: generalized-onset and focal-onset. - *Generalized-onset seizures* involve both sides of the brain. They are characterized by bilateral, synchronous epileptic discharges in the brain. - *Generalized- onset motor tonic-clonic seizure* is characterized by loss of consciousness and falling to the ground if the patient is upright, followed by stiffening of the body (tonic phase) for 10 to 20 seconds and subsequent jerking of the extremities (clonic phase) for another 30 to 40 seconds. - *Absence seizures* usually occur only in children and rarely continue beyond adolescence. *Atypical absence seizure* is characterized by a staring spell and accompanied by other manifestations, such as eye blinking or jerking. - *Focal-onset seizures* are caused by focal irritations. They begin in 1 hemisphere of the brain in a specific region of the cortex. - *Focal awareness seizures* do not involve loss of consciousness and rarely last longer than 1 minute. - *Focal impaired awareness seizures* involve a change in level of consciousness. These seizures usually last longer than 1 minute and are often followed by a period of postictal confusion. - *Focal motor seizures* are characterized by a variety of motor activities. Some people have automatisms*.* - With a focal nonmotor seizure, the patient can have emotional manifestations or strange feelings. - *Status epilepticus* is a state of continuous seizure activity or a condition in which seizures recur in rapid succession without return to consciousness between seizures. It is the most serious complication of seizures and is a neurologic emergency. - Most seizures do not require emergency medical care because they are self-limiting and rarely cause bodily injury. However, if status epilepticus occurs, if significant bodily harm occurs, or if the event is a first-time seizure, medical care should be sought immediately. - Seizure disorder is mainly treated with antiseizure drugs. The goal of therapy is preventing seizures. Drugs must be taken regularly and continuously. Teach the patient the importance of following the specific drug regimen and what to do if a dose is missed. Help the patient and caregivers with self-management techniques. - Patients whose seizures cannot be controlled with drug therapy may be candidates for surgical intervention to remove the focal area. - During the seizure, maintain a patent airway and ensure patient safety. Record the location duration, and details of the event. RESTLESS LEGS SYNDROME {#restless-legs-syndrome.ListParagraph} ====================== - *Restless legs syndrome* (RLS) is characterized by unpleasant sensory and motor abnormalities of 1 or both legs. Two distinct types of RLS have been identified: primary (idiopathic) and secondary. - Primary RLS is thought to be related to dysfunction in the brain's basal ganglia circuits that use dopamine. Secondary RLS can occur with pregnancy, iron deficiency, or renal disease. - The urge to move the legs, often accompanied by uncomfortable sensations, worsens with rest. It is most pronounced in the evening and is partially or fully relieved by movement. - Nonpharmacologic approaches to RLS management include developing regular sleep habits, encouraging exercise, avoiding activities that cause symptoms, and eliminating aggravating factors. - If nonpharmacologic measures fail to provide symptom relief, drug therapy with dopaminergic agents or agonists may be started. Gabapentin enacarbil may decrease sensory sensations. - Drug treatment should be considered for patients who have moderate to severe symptoms that significantly affect sleep or impair daily functioning. MULTIPLE SCLEROSIS {#multiple-sclerosis.ListParagraph} ================== - *Multiple sclerosis* (MS) is a chronic, progressive, degenerative disorder of the central nervous system (CNS) characterized by disseminated demyelination of nerve fibers of the brain and spinal cord. - The cause of MS is unknown. MS is related to infectious (viral), immunologic, and genetic factors. - Disease onset is often gradual, with vague symptoms occurring intermittently over months or years. Some patients have chronic, progressive deterioration, while others have remissions and exacerbations. - Common manifestations of MS include motor, sensory, cerebellar, and emotional problems. - No definitive diagnostic test exists for MS. Diagnosis is based on history, manifestations, and the presence of multiple lesions over time on MRI. - To be diagnosed with MS, the patient must have (1) evidence of at least 2 inflammatory demyelinating lesions in at least 2 different locations within the CNS, (2) damage or an attack occurring at different times (usually 1 month or more apart), and (3) all other possible diagnoses ruled out. - No cure is available for MS. The goal of interprofessional care is treating the disease process and providing symptomatic relief. - Treatment begins with use of immunomodulator drugs to modify disease progression and prevent relapse. These drugs include interferon β-1a (Rebif, Avonex), interferon β-1b, and glatiramer acetate (Copaxone). - Many other drugs are used to treat the various symptoms of MS. Spasticity is treated primarily with muscle relaxants. - Bladder dysfunction and constipation are major problems. Open discussions about their management is essential. - During an acute exacerbation, the patient may be immobile and confined to bed. The focus of nursing intervention at this phase is to prevent major complications of immobility. - Patient teaching should focus on building general resistance to illness, including avoiding fatigue, extremes of heat and cold, and exposure to infection. Exercise and nutrition are valuable. PARKINSON'S DISEASE {#parkinsons-disease.ListParagraph} =================== - *Parkinson's disease* (PD) is a chronic disease of the basal ganglia characterized by increased muscle tone, tremor at rest, gait changes, and slowness in the initiation and execution of movement. - The exact cause of PD is unknown. Researchers believe it results from the complex interplay between environmental factors and the person's genetic makeup. - The classic manifestations of PD include tremor, rigidity, akinesia, and postural instability (TRAP). - *Tremor* can involve the hand, diaphragm, tongue, lips, and jaw. - *Rigidity* is the increased resistance to passive motion when limbs go through their range of motion. - *Akinesia (bradykinesia)* is evident in the loss of automatic movements, such as blinking of the eyelids, swinging of the arms while walking, swallowing saliva, and self-expression with facial and hand movements. - Patients with *postural instability* may describe being unable to stop themselves from going forward (propulsion) or backward (retropulsion). - Many non-motor symptoms are common. They include depression, anxiety, apathy, fatigue, pain, urinary retention and constipation, erectile dysfunction, and memory changes. - Because no cure is available, interprofessional management is aimed at relieving the symptoms. - The goal of drug therapy is to correct an imbalance of neurotransmitters within the CNS. Antiparkinson drugs either enhance the release or supply of dopamine (dopaminergic) or block the effects of the overactive cholinergic neurons in the striatum (anticholinergic). - Surgical procedures may relieve symptoms in patients who are not responsive to drug therapy or have developed severe motor complications. - Encourage physical exercise and promote a well-balanced diet. Direct your teaching and nursing care toward maintaining good health, encouraging independence, and avoiding complications, such as contractures. MYASTHENIA GRAVIS {#myasthenia-gravis.ListParagraph} ================= - *Myasthenia gravis* (MG) is an autoimmune disease of the neuromuscular junction characterized by fluctuating weakness of certain skeletal muscle groups. - Antibodies attack acetylcholine receptors (AChRs) in MG, resulting in a decreased number of AChR sites at the neuromuscular junction. - The muscles most often affected by the fluctuating weakness are those used for moving the eyes and eyelids, chewing, swallowing, speaking, and breathing. - The course of MG is highly variable. Some patients have short-term remissions, others stabilize, and others have severe, progressive involvement. - Drug therapy includes anticholinesterase drugs, alternate-day corticosteroids, and immunosuppressants. - Because the presence of the thymus gland appears to enhance the production of AChR antibodies, removal of the thymus gland results in improvement in most patients. - Plasmapheresis and IV immunoglobin G can yield short-term improvement in symptoms. - *Myasthenic crisis* is an acute exacerbation of muscle weakness triggered by infection, surgery, emotional distress, exposure to certain drugs, or beginning treatment with corticosteroids. - The major complications of MG result from muscle weakness in areas that affect swallowing and breathing. - The patient with MG who is admitted to the hospital usually has a respiratory tract infection or is in an acute myasthenic crisis. Nursing care is aimed at maintaining adequate ventilation, continuing drug therapy, and watching for side effects of therapy. AMYOTROPHIC LATERAL SCLEROSIS {#amyotrophic-lateral-sclerosis.ListParagraph} ============================= - *Amyotrophic lateral sclerosis* (ALS) is a rare progressive neurologic disorder of unknown cause. Motor neurons in the brainstem and spinal cord gradually degenerate, often leading to death within 2 to 5 years. - Progressive muscle weakness and atrophy are the classic signs of ALS. Death often results from compromised respiratory function. - No cure exists for ALS. Riluzole (Rilutek) and Edaravone (Radicava) may slow the progression. - The illness trajectory for ALS is devastating because the patient remains cognitively intact while deteriorating physically. HUNTINGTON'S DISEASE {#huntingtons-disease.ListParagraph} ==================== - *Huntington's disease* (HD) is a progressive, degenerative brain disorder. It is a genetically transmitted, autosomal dominant. - The manifestations include abnormal and excessive involuntary movements (chorea). These writhing, twisting movements of the face, limbs, and body worsen as HD progresses. - Because no cure exists, interprofessional care is palliative. Antipsychotic, antidepressant, and antichorea drugs are prescribed and have some benefit.