Chapter 45 Iggy Interventions for clients with problems of the CNS

							                        Chapter 45
Interventions for Clients with Problems of the Central
             Nervous System: The Brain
                         Headaches
• Migraine headache
• Episodic familial disorder manifested by unilateral,
  frontotemporal, throbbing pain in the head, often worse behind
  one eye or ear
• Often accompanied by a sensitive scalp, anorexia, photophobia,
  nausea
• Aura: sensation that signals the onset of a headache or seizure

                       Drug Therapy
• Abortive therapy: alleviating pain during the early aura phase
  includes prescribing ergotamine derivatives, NSAIDs, triptans,
  isometheptene combinations.
• Acetaminophen and NSAIDs are usually effective for mild
  migraine headaches.
                   Preventive Therapy
• NSAID prescription
• Beta-adrenergic blocker
• Calcium channel blockers


 Complementary and Alternative Therapies
• Yoga, meditation, massage, exercise, biofeedback, relaxation
  techniques
• Acupuncture
• Use of herbs and nutritional therapies with approval
• Avoidance of trigger events that may result in migraine episodes,
  such as tension and stress
                    Cluster Headache
• Histamine cephalagia, uncommon type of headache
• Cause unknown; attributed to vasoreactivity and oxyhemoglobin
  desaturation
• Unilateral, radiating to forehead, temple, or cheek
• Ipsilateral tearing of the eye, rhinorrhea, ptosis, and miosis
                              Therapy
•   Same types of drugs used for migraines
•   Client to wear sunglasses and avoid sunlight
•   Oxygen via mask
•   Avoidance of precipitating factors, such as anger, excitement
•   Surgical management
                      Tension Headache
• Neck and shoulder muscle tenderness and bilateral pain at the
  base of the skull and in the forehead
• Head pain without associated symptoms
• Treatment: non-opioid analgesics, muscle relaxants, occasional
  opioids
• Ibuprofen plus caffeine
• Prophylactic treatment similar to that used in treating migraine
  headaches
                   Seizures and Epilepsy
• Seizure: abnormal, sudden, excessive, uncontrolled electrical
  discharge of neurons within the brain; may result in alteration in
  consciousness, motor or sensory ability, and/or behavior
• Epilepsy: chronic disorder with recurrent, unprovoked seizures;
  may be caused by abnormality in electrical neuronal activity,
  and/or imbalance of neurotransmitters (such as GABA)

                      Types of Seizures
• Generalized seizures
• Partial seizures
• Unclassified seizures
                      Types of Epilepsy
• Primary or idiopathic epilepsy: not associated with any
  identifiable brain lesion
• Secondary epilepsy: results from an underlying brain lesion, most
  commonly a tumor or trauma
                       Seizures Risks
• Seizures may result from:
   • Metabolic disorders
   • Acute alcohol withdrawal
   • Electrolyte disturbances
   • Heart disease
             Collaborative Management
• A complete description of the type of seizure activity that occurs
  and events surrounding the seizure determines the best treatment
  plan.
• Determine whether an aura was present before the seizure in the
  preictal phase.
• Diagnostic testing is performed.

                        Drug Therapy
• Evaluate most current blood level of medication, if appropriate.
• Be aware of drug-drug and drug-food interactions.
• Maintain therapeutic blood levels for maximal effectiveness.
                                                            (Continued)
                Drug Therapy (Continued)
• Do not administer warfarin with phenytoin.
• Document and report side and adverse effects.

            Client and Family Education
• Antiepileptic drugs (AEDs) may not be stopped, even if seizures
  stop.
• Refer limited-income clients to social services.
• All states prohibit discrimination against people who have
  epilepsy.
                                                               (Continued)
       Client and Family Education (Continued)
• Alternative employment may be needed.
• Vocational rehabilitation may be subsidized.
                    Seizure Precautions
•   Oxygen and suctioning equipment should be readily available.
•   Saline lock may be necessary.
•   Side rails should be up at all times.
•   Padded side rail use is controversial.
•   Place bed in lowest position.
•   Never insert padded tongue blades into the client’s mouth during
    a seizure.
                    Seizure Management
• If simple partial seizure, observe the client and document the
  seizure.
• Turn the client on the side during a generalized tonic-clonic
  seizure; if possible, turn the client’s head to prevent aspiration.
• Cyanosis usually is self-limiting.
• Do not restrain.
           Status Epilepticus Management
• Usual causes of status epilepticus:
  • Prolonged seizures lasting more than 5 minutes or repeated
    seizures over the course of 30 minutes
  • Neurologic emergency that must be treated promptly and
    aggressively
  • Sudden withdrawal of AEDs, infections, alcohol withdrawal,
    head trauma, cerebral edema, and metabolic disturbances
              Status EpilepticusTreatment
•   Establish an airway.
•   Administer oxygen as indicated.
•   Establish intravenous access.
•   For continuous monitoring, admit client to intensive care unit.
•   Give IV diazepam, lorazepam, phenytoin, fosphenytoin, or general
    anesthesia.
                                                           (Continued)
       Status EpilepticusTreatment (Continued)
• Other treatments include:
  • Surgical management: epileptic region in a resectable area
  • Corpuscallostomy
  • Vagal nerve stimulation
                          Meningitis
• Meningitis: inflammation of the arachnoid and pia mater of the
  brain and spinal cord and the cerebrospinal fluid
• Bacterial and viral origins most common: fungal and protozoal
  meningitis
                                                           (Continued)
                   Meningitis (Continued)
• Viral meningitis: self-limiting and client recovers
• Bacterial meningitis: a medical emergency with a mortality rate of
  approximately 25%.

          Physical Assessment and Clinical
                   Manifestations
• Signs and symptoms of meningitis: headache, nausea, vomiting,
  and fever
• Photophobia and indications of increased intracranial pressure
• Nuchal rigidity and positive Kernig’s and Brudzinski’s signs (only
  present in 9% of clients)
• Seizure, decreased mental status, focal neurologic deficits
       Laboratory Assessment of Meningitis
•   Cerebrospinal fluid analysis
•   Computed tomography scan
•   Blood cultures
•   Counterimmunoelectrophoresis
•   Polymerase chain reaction
•   Complete blood count
• X-ray study to determine presence of infection
                         Drug Therapy
•   Broad-spectrum antibiotic
•   Hyperosmolar agents
•   Anticonvulsants
•   Steroids (controversial)
•   Prophylaxis treatment for those who have been in close contact
    with the meningitis-infected client
                          Encephalitis
• Inflammation of the brain parenchyma and often the meninges;
  affects the cerebrum, brainstem, and cerebellum
• Viral cause, most often bacteria, fungi, or parasites
• Degeneration of neurons of the cortex
• Hemorrhage, edema, necrosis, small lacunae develop in cerebral
  hemispheres
                         Interventions
• Prompt recognition and treatment of signs of cerebral edema,
  hemorrhage, and necrosis of brain tissue
• Establishment of patent airway
• Assessment of vital signs
• Continuous supportive care and assessment

                     Parkinson Disease
• Debilitating disease affecting motor ability characterized by
  tremor, rigidity, akinesia, and postural instability
• Parkinson disease is separated into stages by degree of disability:
  1, 2, 3, 4, and 5.
• Exact cause unknown, possibly involving environmental and
  genetic factors
                          Assessment
• Fatigue, slight tremor, problems with manual dexterity
• Rigidity, changes in facial expression, uncontrolled drooling,
  dementia, changes in voluntary movement, excessive perspiration,
  orthostatic hypotension
• No specific diagnostic tests
         Drug Therapy in Parkinson Disease
•   Anticholinergic drugs: amantadine, selegiline (confer mild benefit)
•   Dopamine agonists in the first 3 to 5 years
•   Levodopa
•   Bromocriptine or pergolide
•   Amantadine

                          Drug Toxicity
• Long-term drug therapy regimens often cause delirium, cognitive
  impairment, decreased effectiveness of the drug, or hallucinations.
• Reduce medication dose.
• Change medications or frequency of administration.
• Take “drug holiday,” especially in the use of levodopa therapy.
         Management of Parkinson Disease
•   Exercise and ambulation
•   Self-care
•   Injury prevention
•   Nutrition
•   Communication
•   Psychosocial support

                                                              (Continued)
    Management of Parkinson Disease (Continued)
• Surgical management includes:
   • Deep brain stimulation
   • Fetal tissue transplantation


                    Alzheimer’s Disease
• Chronic, progressive, degenerative disease that accounts for 60%
  of dementias occurring in people older than 65 years of age
• Loss of memory, judgment, and visuospatial perception, and
  change in personality
• Increasing cognitive impairment, severe physical deterioration,
  death from complications of immobility
            Structural Changes in the Brain
• Alzheimer’s disease creates changes that include:
  • Neurofibrillary tangles
  • Senile or neuritic plaques
  • Increased amounts of an abnormal protein, beta amyloid
                                                               (Continued)
     Structural Changes in the Brain (Continued)
    • Significantly increased vascular degeneration a contributor to
      mortality in this disorder
    • Abnormalities of ACH, norepinephrine, dopamine, and
      serotonin

            Chemical Changes in the Brain
• Alzheimer’s disease creates changes that include abnormalities in
  the neurotransmitters:
   • Acetylcholine
   • Norepinephrine
   • Dopamine
   • Serotonin
• Their exact role is not well understood.
                         Manifestations
•   Changes in cognition
•   Alterations in communication and language abilities
•   Changes in behavior, personality, and judgment
•   Changes in self-care skills
•   Psychosocial assessment, especially client’s reaction to changes in
    routine
        Interventions in Alzheimer’s Disease
• Answer client’s questions truthfully.
•   Assess and treat other medical problems.
•   Provide cognitive restructuring and memory training.
•   Structure the environment to increase client’s ability to function.
•   Prevent overstimulation.
                          Interventions
• Provide consistency, orientation, and validation therapy.
• Promote independence in activities of daily living.
• Promote bowel and bladder continence.

                                                               (Continued)


                   Interventions (Continued)
• Assist with facial recognition as the disease progresses to
  prosopagnosia, an inability to recognize oneself and other familiar
  faces.
• Promote communication with clear, short sentences.


                          Drug Therapy
•   Cholinesterase inhibitors
•   Memantine
•   Donepezil
•   Antidepressants
•   Psychotropic drugs
•   Complementary and alternative therapies
                          Risk for Injury
• Interventions for the client with Alzheimer’s disease include:
   • Coping with restlessness and wandering; ensuring client wears
     identification bracelet; registering client in Safe Return
     Program; providing frequent walks and structured activities
                                                               (Continued)
                   Risk for Injury (Continued)
    • Ensuring safety by removing all potentially dangerous objects,
    particularly in case seizures occur
  • Minimizing agitation by talking calmly and softly; displaying
    positive affect; making calm movements; offering diversion
            Compromised Family Coping
• Interventions for the caregiver role:
   • Encourage family to seek legal counsel regarding client’s
     competency, need to obtain guardianship, or durable medical
     power of attorney, when necessary.
   • Make caregivers and family aware of their own health and
     stress resulting from new responsibilities for care.
                Disturbed Sleep Pattern
• Difficulty sleeping at night with frequent naps in the day
• Interventions for establishing sleep pattern:
   • Re-establish the usual day-night pattern by providing activity
     and exercise during the day.
   • Establish before-bedtime ritual.
                                                            (Continued)
         Disturbed Sleep Pattern (Continued)
  • Adjust treatment and medication schedule to provide for
    uninterrupted sleep.
  • Give mild antianxiety agent or hypnotic.

                   Huntington Disease
• Hereditary disorder transmitted as an autosomal dominant trait
  at the time of conception
• Gradual clinical onset of progressive mental status changes,
  leading to dementia and choreiform movements in the limbs,
  trunk, and facial muscles
• Three stages each lasting about 5 years over an average 15 years
  of the disease
      Management of Huntington Disease
• No known cure or treatment
• Genetic counseling
• Antipsychotic agents or monoamine-depleting agents used to
  manage movement abnormalities that are disabling or interfere
  with ADLs
• Medications to treat depression, anxiety, and obsessive-compulsive
  behaviors