Nursing care and interventions for Neurological Disorders

							Neurological Disorders
      Adult Health I
          Seizure Disorders
 Episodes of abnormal motor, sensory,
  autonomic or psychic activity ( or any
  combination) that result from sudden
  excessive discharge from cerebral neurons
 May be brought on by part of the brain or
  all of the brain may be involved
              Causes of Seizures
   Idiopathic
   Cerebrovascular disease
   Hypoxemia
   Fever (childhood)
   Hypertension
   Head injury                      Acquired
   CNS infections
   Metabolic and toxic conditions
   Brain Tumor
   Drug / alcohol withdrawal
   Allergies
            Types of Seizures
   Simple Partial
    – No LOC
    – May produce abnormal sensations, such as an
      unpleasant smell, or a motor movement, such
      as jerking of the arm
   Complex Partial
    – Likely has impairment of consciousness
   Partial Seizures Secondarily Generalized
             Types of Seizures
   Generalized
    – LOC usual
    – Sx bilaterally symmetric
    – Absence: Previously known as petit mal, triggers a
      short lapse in consciousness. Most often seen in
      children
    – Atonic: Previously known as a drop attack, causes a
      complete loss of muscle control and results in
      collapse
    – Myoclonic: Triggers sudden jerking in the muscles,
      often in the arms and legs
    – Tonic-clonic: Triggers a fall to the ground (tonic
      phase) followed by jerking movements (clonic phase)
          Absence Seizure


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         Medical Management
   Pharmacologic Therapy
    – May need more than 1 medication to control
    – Some drugs more effective for certain types
      of seizures
    – Can control up to 70-80% of all seizures
    – Meds may need to be adjusted during illness,
      weight changes or increases in stress
    – Side effects are problematic and can be
      frequent
          Medical Management
   Tegretol
   Lamictal
   Dilantin
   Phenobarbital
   Keppra
   Topamax
   Depakote
   Neurontin
   Ativan
   Klonopin
          Medical Management
   Common side effects of anti-seizure
    medications
    – Sedation, dizziness, fatigue, gi complaints,
      vision disturbances, weight gain, gait
      disturbances
   Toxic effects of anti-seizure medications
    – Blood dyscrasias
    – Hepatitis and/or hepatotoxicity
    – Skin rashes
    – Nephrolithiasis
         Surgical Management
 Excision of lesion
  causing seizure
 Vagus Nerve
  Stimulator-
  implantation of
  generator to deliver
  electrical impulses to
  the brain
    Nursing Care During a Seizure
   Observe and record findings
    – Circumstances prior to seizure
    – Aura
    – Description of behaviors (gaze, movements, head and
      body position, etc)
    – Pupillary response
    – Presence/absence of automatisms
    – Incontinence
    – Unconsciousness
    – Cognitive function
    – Weakness after seizure
    – Sleeping after seizure
    Nursing Care During a Seizure
   Prevent complications during seizure
    – Turn the patient to the side
    – Do not force anything into the mouth
    – Suction if needed
    – Pad siderails
    – Bed in low position
    – Loosen constrictive clothing
    – Provide privacy
    Nursing Care During a Seizure
   Documentation example:
    11/6/07 3:15pm – Pt reported hearing buzzing in right ear 30
      seconds prior to onset of seizure. During seizure, pt was
      unconscious, head turned toward the right with bilateral tonic-
      clonic movements of upper and lower extremities and lip
      smacking. Eyes open and deviated to the right. Pupils fixed at
      6mm bilaterally. Pt was incontinent of urine. Seizure lasted
      approximately 2 minutes. Vital signs at termination of seizure: p-
      100, r-22, bp-100/68. Pt lethargic, speech garbled at termination
      of seizure and pt fell asleep. Safety measures implemented.
      Nurse remained with pt for duration of seizure with no evidence
      of injury. Dr Jones notified of events. No new orders received.
      Joann Paoletti, RN.
    4:00pm- pt awake, alert, oriented x3. Has no recollection of events
      occurring after aura. Joann Paoletti, RN.
          Nursing Management
   Pt / family education
    – Medication use, dose, side effects
    – What to do in event of seizure
    – Avoidance of triggers
 Lifestyle changes
 Coping skills and stress management
 Monitoring for complications
               Stroke
 “Brain Attack”
 Main Types:
    – Ischemic
        Sudden loss of function due to disrupted blood flow to the
         brain leading to brain cell injury and death
        Caused by: thrombus, embolus, atherosclerosis
    – Hemorrhagic
        Sudden loss of function due to rupture of cerebral vessel,
         thus reducing blood flow
        Caused by: uncontrolled hypertension or aneurysm
    – Stroke cause by other problems
        Illicit drug use, migraine, coagulopathies, etc
   Transient Ischemic Attack (TIA) – stroke sx
    which resolve <24h
       Clinical Manifestations
 Numbness or weakness of the face, arm
  or leg, esp on 1 side of the body
 Confusion or change in mental status
 Trouble speaking or understanding speech
 Visual disturbances
 Difficulty in walking, dizziness, or loss of
  balance or coordination
 Sudden severe headache
            Types of Deficits
Motor Deficits
 Hemiparesis- weakness of 1 side of the body
 Hemiplegia- paralysis of 1 side of the body
 Ataxia- gait disturbance
 Dysarthria- difficulty in speaking
 Dysphagia- difficulty in swallowing
Sensory Deficits
 Parasthesia- numbness or tingling
          Types of Deficits
Verbal Deficits
 Expressive aphasia- unable to form
   words
 Receptive aphasia- unable to
   comprehend the spoken word
 Global aphasia- mixed with expressive
   and receptive features
           Types of Deficits
Cognitive Deficits      Emotional Deficits
 Short and long term    Loss of self-control
  memory loss            Emotional lability
 Decreased attention    Decreased tolerance
  span                    to stress
 Impaired ability to    Depression
  concentrate            Withdrawal
 Poor abstract
                         Fear, hostility, anger
  reasoning
                         Feelings of isolation
 Altered judgment
              Comparison of Left
            and Right Sided Strokes
Left Hemispheric Stroke
 Right sided weakness
 Right visual field deficit
 Aphasia (expressive, receptive
   or global)
 Altered intellectual ability
 Slow, cautious behavior


Right Hemispheric Stroke
 Left sided weakness
 Left visual field deficit
 Spatial-perceptual difficulties
 Increased distracability
 Impulsive behavior and poor
   judgement
 Lack of awareness of deficits
    Assessment and Diagnostics
 Complete h/p with detailed neuro
  assessment
 Non-contrast CT of Head
 12 lead ekg
 Carotid ultrasound
 Echocardiogram
 MRI/MRA
          Stroke Risk Factors
Modifiable                Nonmodifiable
 Hypertension             Advanced age
 Hyperlipidemia           Male gender
 Obesity                  African-American
 Smoking                   ethnicity
 Diabetes
 Periodontal disease
 Excessive alcohol use
           Medical Management
   Primary Prevention
    – Identify those at risk and educating them about
      lifestyle changes
    – Low dose aspirin
   Secondary Prevention
    – Warfarin
        Goal to keep INR 2-3
    – Antiplatelet therapy
        Plavix 75mg/day
    – Statins
    – HCTZ and ACEI for BP control
           Medical Management
   Thrombolytics to destroy clot
    – Must be given within 3h of onset of sx
   Carotid Endarterectomy
    – Removal of atherosclerotic plaque
   Carotid Stenting
    – Stent placed in carotid artery to keep vessel open
 Craniotomy with evacuation of bleed and repair
  of aneurysm
 Ventriculostomy
    – Drain to manage ICP
         Nursing Management
   Improve joint mobility and prevent joint
    deformities
    – Establish exercise program
    – Position arm to prevent shoulder adduction
    – Position hand and fingers
    – Change positions
    – Prevent shoulder pain
            Nursing Management
   Enhance self-care
    – Use assistive devices
   Prepare for ambulation
    – Work on sitting, then standing
    – Position pt to use “good” side to help with transfer
   Promote adequate nutrition
    –   Assist with feedings as needed
    –   Speech therapy referral
    –   Change consistency of food/fluids
    –   May need tube feedings if dysphagia severe
          Nursing Management
   Manage sensory-perceptual difficulties
    – Use visual stimuli
    – Keep stimuli on side where vision is intact
    – Encourage involvement of affected side
   Attain bowel/bladder control
    – Toileting schedule
    – Kegel exercises
    – Intermittent cath
    – High fiber diet with at least 2l fluid/day
            Nursing Management
   Improve thought processes
    – Reality orientation
    – Cueing
    – Provide positive feedback
   Improve communication
    –   Speak slowly and clearly
    –   Allow the patient to speak
    –   Use posted schedules to aid with daily events
    –   Repetition
    –   Use gestures, pictures, etc
    –   Give 1 instruction at a time
    –   Talk to the patient
           Nursing Management
   Maintain skin integrity
    – Turn and position
    – Pressure reducing devices
    – Keep skin clean and dry
   Improve patient/family coping
    – Encourage verbalization of feelings
    – Incorporate pt/family into care
   Promote community based care
    – Refer to home care agency
    – Reinforce need for secondary prevention measures
              Parkinson’s Disease
   Slowly progressive neurological movement
    disorder
   There is decreased dopamine, thus allowing
    acetylcholine to be unchecked resulting
    imbalance which affects voluntary movements
   Leads to disability
   Sx usually appear in 50s or later
   Affects more men than women
   Cause unclear       http://video.google.com/videoplay?docid=77
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       Clinical Manifestations
 Tremors
 Rigidity
 Bradykinesia
 Postural instability
 Shuffling gait
 Micrographia
 Dysphonia
 Mask-like facies
       Other Manifestations
 Dementia
 Dysphagia
 Constipation
 Urinary retention
 Sleep disturbances
 Depression
 Psychosis
     Assessment and Diagnostics
   Dx based on clinical presentation with at
    least 2 of the following:
    – tremor
    – Rigidity
    – Bradykinesia
    – Postural changes
   PET scan may be helpful
            Medical Management
   Anti-Parkinson meds
    – Replace dopamine (Sinemet)
    – ? Whether or not they advance disease and promote dyskinesia
      and “on-off” effects
   Anticholinergic meds
    – Cogentin
    – Can be used with dopamine agents
   Antiviral meds
    – Symmetrel
    – Exact mechanism unknown
   Dopamine Agonists
    – Parlodel, Requip, Mirapex, etc
    – Work by prolonging availability of dopamine by stimulating
      dopamine receptors
            Medical Management
   Monoamine Oxidase (MAO) Inhibitors
    – Eldepryl
    – Inhibits dopamine breakdown
    – Drug-food interactions
   COMT Inhibitors
    – Comtan
    – Useful adjunct medication
    – Blocks enzyme that breaks down levodopa
   Antidepressants
    – TCAs (Elavil) often used due to anticholinergic and
      antidepressant effects
    – Some SSRIs can aggravate Parkinson’s
   Antihistamines
    – Used for anticholinergic and sedative effects
           Medical Management
   Sterotactic Surgery
    – Part of nerve pathway permanently destroyed, thus
      alleviating sx
   Neural Transplantation
    – Stem cell transplantation
        http://stemcells.nih.gov/info/basics/defaultpage.asp
    – Creates ethical issues
   Deep Brain Stimulation
    – Pacemaker like device surgically implanted
       Nursing Management
 Improve mobility
 Enhance self-care activities
 Improve bowel elimination
 Improve nutrition
 Enhance swallowing
 Improve communication
 Support coping abilities
 Promote use of community resources
          Multiple Sclerosis
 Immune mediated progressive
  demyelinating disease of the CNS
 Destruction of myelin sheath interferes
  with transmission of nerve impulses
 More women affected
 Dx between ages 20-50
          Clinical Manifestations
   Fatigue
   Depression
   Loss of balance
   Pain
   Weakness
   Numbness
   Poor coordination
   Blurred or double vision
   Spasticity
       Other Manifestations
 Bladder dysfunction
 Bowel dysfunction
 Pressure ulcers
 Dysphagia
 Dysphonia
 Sexual dysfunction
 Depression
Types of MS
    Assessment and Diagnostics
 Complete h/p with detailed neuro hx
 MRI
 Spinal tap
         Medical Management
   MS Drugs
    – Rebif, Betaseron
    – Copaxone, Avonex
    – Solumedrol
    – Novantrone
   Symptom Management
    – Baclofen
    – Zanaflex
    – Benzodiazepines
          Nursing Management
   Promote physical mobility
    – Exercise
    – Minimize spasticity and contractures
    – Rest periods
 Prevent injury
 Enhance bowel and bladder control
    – Routine toileting
    – Intermittent catheterization
    – Bowel training program
              Nursing Management
   Enhance communication and swallowing problems
    –   Speech therapy referral
    –   Alter consistency of food/fluids
    –   Assist with meals
    –   Monitor for aspiration
   Improve sensory/cognitive function
    – Eye patch for double vision
    – Prism glasses
    – Provide support and assist with coping skills
   Improve home management
    – Environment handicap equipped
    – Assistive devices
                    Case Study
BD is a 70y AAF who lives in an assisted living facility. She
  has a hx of HTN and CAD. She woke up in the morning
  with right sided weakness and slurred speech. On
  admission to the hospital, cardiac rhythm- atrial
  fibrillation. P- 98, R- 20, BP 136/88. She is awake and
  alert. Speech is garbled and she cannot follow one step
  directions. She has paralysis of her right side.
        1. What diagnostic tests might be done?
        2. What is likely going on?
        3. What medical treatments might be appropriate?
        4. What nursing interventions would be appropriate?
        5. Can this patient return to the ALF after discharge?