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Chapter 44

Chapter 44
Care of Patients with Problems of the
Central Nervous System: The Brain
Mrs. Marion Kreisel MSN, RN
NU230 Adult Health 2
Fall 2011
• Migraine headache—chronic, episodic disorder with multiple
• Stages:
• Prodrome: pt has specific symptoms such as food
cravings or mood changes
• Aura phase: visual changes, flashing lights, or diplopia
• Headache phase: few hours to a few days
• Termination Phase: intensity of headache decreases
• Postrodrome: fatigues, irritable, and has muscle pain
• Recognize migraine symptoms
• Respond and see health care provider
• Relieve pain and associated symptoms
Drug Therapy
• Abortive therapy—alleviating pain during the
early aura phase or soon after the headache has
• Preventive therapy
Complementary and Alternative
• Yoga, meditation, massage, exercise,
biofeedback, relaxation techniques
• Acupuncture
• Use of herbs and nutritional therapies with
• Avoidance of trigger events that may result in
migraine episodes, such as tension and stress
Cluster Headache
• Histamine cephalalgia
• Cause unknown; attributed to vasoreactivity and
oxyhemoglobin desaturation
• Unilateral, radiating to forehead, temple, or cheek
• Ipsilateral (same side) tearing of the eye,
rhinorrhea, ptosis (drooping of eye lid), and
miosis (contraction of eye pupil)
Same types of drugs used for migraines
Patient to wear sunglasses and avoid sunlight
Oxygen via mask
Avoidance of precipitating factors, such as anger,
• Surgical management
Tension Headache
• Neck and shoulder muscle tenderness and
bilateral pain at the base of the skull and in the
• 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
• Epilepsy—two or more seizures experienced by a
person; chronic disorder with recurrent,
unprovoked seizure activity, may be caused by
abnormality in electrical neuronal activity and/or
imbalance of neurotransmitters (e.g., GABA)
Types of Seizures
• Generalized seizures
• Partial seizures
• Unclassified seizures
• Primary or idiopathic epilepsy—not associated
with any identifiable brain lesion
• Secondary seizures—result 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
• High fever
• Stroke
• Substance abuse
Nonsurgical Management
• Antiepileptic drugs (AEDs)
• Importance of compliance
• Health teaching
Seizure Precautions
Suction equipment
IV access
Siderails up
No tongue blades
Seizure Management
Will depend on the type of seizure
Observation and documentation
Patient safety
Side-lying position
No restraints
Acute Seizure Management
Lorazepam (Ativan)
Diazepam (Valium)
Diastat (form of valium)
IV phenytoin (dilatin) or fosphenytoin (Cerebyx)
Status Epilepticus
• Medical emergency
• Prolonged seizures lasting more than 5 minutes
or repeated seizures over the course of 30
• Establish an airway
• ABGs
• IV push lorazepam, diazepam; rectal diazepam
• Loading dose IV phenytoin
Drug Therapy
• Evaluate most current blood level of medication,
if appropriate.
• Be aware of drug-drug and drug-food
• Maintain therapeutic blood levels for maximal
• Do not administer warfarin with phenytoin.
• Document and report side and adverse effects.
Patient and Family Education
• Antiepileptic drugs (AEDs) may not be stopped,
even if seizures stop.
• Refer limited-income patients to social services.
• All states prohibit discrimination against people
who have epilepsy.
• 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.
• Siderails should be up at all times.
• Padded siderail use is controversial.
• Place bed in lowest position.
• Never insert padded tongue blades into the
patient’s mouth during a seizure.
Seizure Management
• If simple partial seizure, observe the patient and
document the seizure.
• Turn the patient on the side during a generalized
tonic-clonic seizure; if possible, turn the patient’s
head to prevent aspiration.
• Cyanosis usually is self-limiting.
• Do not restrain.
Surgical Management
Vagal nerve stimulation (VNS)
Conventional surgical procedures
Anterior temporal lobe resection
Partial corpus callosotomy treats tonic clonic
movments. Surgically resects 2/3 of the corpus
callosum to decrease repaid firing
• Meningitis—inflammation of the meninges that
surround the brain and spinal cord
• Viral meningitis—usually self-limiting and the
patient has a complete recovery
• Bacterial meningitis—potentially life-threatening
Physical Assessment and Clinical
• 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
• Seizure, decreased mental status, focal
neurologic deficits
Laboratory Assessment of Meningitis
Cerebrospinal fluid analysis
Computed tomography scan
Blood cultures
Polymerase chain reaction
Complete blood count
X-ray study to determine presence of infection
Drug Therapy
Broad-spectrum antibiotic
Hyperosmolar agents
Steroids (controversial)
Prophylaxis treatment for those who have been in
close contact with the meningitis-infected patient
• Inflammation of the brain tissue and surrounding
• Caused by viral agents: Can be life threatening or
lead to persistent neurologic problems as
learning disabilities, epilepsy, memory and fine
motor deficits. Bacteria, fungi, or parasites
• Degeneration of neurons of the cortex
• Hemorrhage, edema, necrosis, small lacunae
develop in cerebral hemispheres
Hemorrhagic Encephalitis
• 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
• Progressive neurodegenerative disease that is
the third most common neurologic disorder of
older adults
• Tremor, rigidity, bradykinesia (slow movemnet),
or akinesia (no movement)
• Dopamine inhibits the function of excitatory
neurons allowing control over voluntary
Parkinson Disease masklike facial
Wide open
Fixed staring
• Fatigue, slight tremor, problems with manual
• 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
Dopamine agonists: mimic dopamine stimulating
receptors in the brain (apomorphine (Apokyn),
pramipexole ( Miraprex)
Catechol O-methyltransferases (COMTs) are
enzymes that imactivate dopamine and prolong
levodopa ex. Entacapone (Comtan)
Monoamine oxidase type B (MAO-B) inhibitors
Dopamine receptor antagonists (mesylate (Azilect)
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
• Take “drug holiday,” especially in the use of
levodopa therapy.
Management of Parkinson Disease
• Exercise and ambulation, improve mobility
(yoga, exercise late morning, look down when
getting out of chairs etc.)
• Self-management
• Injury prevention
• Nutrition
• Communication
• Psychosocial support
Management of Parkinson Disease
• Surgical management includes:
• Stereotactic pallidotomy/thalamotomy
• 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
• Loss of memory, judgment, and visuospatial
perception and change in personality
• Increasing cognitive impairment, severe physical
deterioration, death from complications of
Structural Changes in the Brain
• Alzheimer’s disease creates changes that
• Neurofibrillary tangles: Tangled mass of fibroid
tissue in brain
• Neuritic plaques: degenerativenerve terminals
inrease beta amyloid.
• Vascular degeneration: loss of nerve cel to
regenerate properally
• Changes in neurotransmitters
• Increased amounts of an abnormal protein,
beta amyloid
• Changes in cognition
• Alterations in communication and language
• Changes in behavior, personality, and
• Changes in self-care skills
• Psychosocial assessment, especially patient’s
reaction to changes in routine
Interventions in Alzheimer’s Disease
• Answer patient’s questions truthfully.
• Assess and treat other medical problems.
• Provide cognitive stimulation and memory
• Structure the environment to increase patient’s
ability to function.
• Prevent overstimulation.
• Orientation and validation therapy. Orientation therapy
for early stages of AD and validation therapy for late chronic
stages of AD.
Promote self-management.
Promote bowel and bladder continence.
Assist with facial recognition.
Promote communication.
Drug Therapy PG 976
Donepezil, galantamine, rivastigmine
Psychotropic drugs
Risk for Injury
• Interventions for the patient with Alzheimer’s
disease include:
• Coping with restlessness and wandering;
ensuring patient wears identification bracelet;
registering patient in Safe Return Program;
providing frequent walks and structured
Risk for Injury (Cont’d)
• 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
• Restraints should be a last resort. If
restraints applied know all nursing
Compromised Family Coping
• Interventions for the caregiver role:
• Encourage family to seek legal counsel
regarding patient’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.
Disturbed Sleep Pattern (Cont’d)
• 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
• Movement disorder characterized by both
neurologic and behavioral symptoms
• Gradual clinical onset of progressive
mental status changes, leading to
dementia and choreiform (rapid jerky
movemnets) 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
Question 1
What is a priority nursing intervention for a 53-year-old
woman with new onset of severe headaches with
A. Management of associated nausea and vomiting
B. Identification of triggers that cause headaches
C. Evaluation and education of cardiovascular and stroke signs and
D. Effective pain management
Question 2
What is the primary expected outcome for a
patient with
Parkinson disease?
Progressive difficulty with mobility
Severe dementia
Difficulty with effective communication
Question 3
What percentage of people in the United
States can
control their seizures with medication?
Question 4
The older patient states that he has recently noted
changes in his
cognition and worries he is developing Alzheimer’s
disease. The
nurse suspects the patient is not experiencing
symptoms because he:
A. Is also experiencing hallucinations
B. Has only mild memory loss
C. Has recently been placed on a medication regimen
that could affect cognition
D. Is not experiencing changes in his eyesight
Question 5
Alzheimer’s disease accounts for what
percentage of
the dementias occurring in people older than
65 years?
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