Neurological Dysfunction 2005 STUDENT COPY(1)

8/13/2019 Neurological Dysfunction 2005 STUDENT COPY(1)

1/100


2/100


3/100

Migraines

Tend to have pattern

Possible etiology:

Familial

Stress

Hormonal

Three types of migraines:

Classic Common

Complicated

Corsetti


4/100

Classic Migraines

Aura

Transient

neurological

disturbance

Crescendo quality

Unilateral / Spreads

across

Acutely ill

Irritable

N/V

Sensitive to

Light Sounds

Corsetti


5/100


6/100

Migraines-Rx(Pharmacological)

Combination drugs:

Analgesics

VasoconstrictorsAntiemetics

Antidepressants

Sedatives

Corsetti


7/100

Migraines-Rx(Pharmacological cont.)

Prevention

NSAIDs

Beta blockers Calcium Cannel

Blockers

Antidepressants

Abortive Therapy

NSAIDs

Ergotaminederivatives

Triptan

preparations

Antiemetics

Corsetti


8/100

Cluster Headaches

Excruciating pain

No aura

Unilateral

Lacrimation

Miotic pupil on affected side

Facial sweating

Recur in clusters

Corsetti


9/100

Cluster Headaches

Management

Analgesics

Relaxation techniques

Meditation

Acupuncture

Massage therapy

100% O2very effective

Corsetti


10/100

Seizures

Corsetti


11/100

Seizures SZ) Pathophysiology

Sudden / Excessive / Disorderly

Electrical discharge across the brain

Results:

Violent & involuntary contractions of agroup of muscles

Corsetti


12/100

Seizures cont) Epilepsy

Chronic disorder

Characterized by recurrent seizures

Status epilepticus

Generalized seizures

At frequent intervals

Person cannot regain full consciousness EMERGENCY !!!

Corsetti


13/100

Secondary EpilepsyPossible causes

Head trauma

Brain tumors

Aneurysms

Meningitis / Other infections Vascular Ds

Metabolic

F & E imbalance

Meds Kidney & Liver failure / HD

Corsetti


14/100

Seizures Classification) Generalized seizures

Tonic-clonic (grand mal)

Absence (petit mal)

Myoclonic Atonic

Partial seizures Simple partial

Complex partial

Unclassified

Corsetti


15/100

Generalized Sz:TonicClonic

Usually preceded by aura

Tonic phase

Immediate LOC Clonic phase

Postictal phase

May have incontinence

Corsetti


16/100

Generalized Sz:Absence Sz Grand Mal)

No aura

Brief LOC

Blank stare, daydreaming May have little tonic-clonic movements

ie: Twitching of eyelids

No postictal state

Corsetti


17/100

Generalized Sz cont) Myoclonic Sz

Brief jerking or stiffening of extremities

No aura

No LOC

No postictal period

Atonic Sz

Sudden loss of muscle tone

Usually person falls Drop Attack

Postictal confusion

Corsetti


18/100

Partial Seizures Partial complex

LOC

Automatism

Lip smacking

Patting

Picking

? Amnesia

Simple partial

Often aura

No LOC

Unilateral

movements of an

extremity

Corsetti


19/100

Antiepileptic Drugs *Phenytoin

Dilantin

*Carbamazepine Tegretol

Phenobarbital Lumnial

Clonazepam Klonopin

Corsetti


20/100

Antiepileptic Drugs cont) *Divalproex

Depakote

Gabapentin Neurontin

Diazepam Valium

Lorazepam Ativan

Corsetti


21/100

Seizures:Assessment

Subjective Data:

Pt understanding of Ds, triggering factors

Frequency, length of episodes

Pt knowledge of meds

Pt compliance with meds

Description of Sz Aura

Postictal state

Incontinence

Loss of consciousness, amnesia

Corsetti


22/100

Seizures:Assessment cont)

Objective Data:

Description of Sz

Behavior during episode

Characteristics of SzFrequency

Corsetti


23/100

Assessment cont)Diagnostic Data

EEG, CT scan, MRI, LP

CBC, BUN / Cr, Lytes

BS, LFTs, UA

Any underlying disorder

Corsetti


24/100

Seizures:Major Nsg Dx

**Risk for injury

Major consideration

Knowledge deficit Risk for isolation

Risk for depression

Risk for drug side-effects..

Corsetti


25/100

SeizuresNOC

Injury prevention

Awareness of:

Ds, Rx, & possible side-effects

Isolation Avoidance

Depression

Avoidance Normalization of daily living ..

Corsetti


26/100

Seizure Precautions

May vary based one institutions

In general:

O2 & suction set up Airway at bedside

INT

Padded side rails (controversial)

Bed in low position

Side rails up

Corsetti


27/100

SeizuresNIC Interventions general)

Protect client from injury

No restraints

Do not place objects in mouth

Turn client to side as soon as possible Loosen restrictive clothing

Maintain airway

Suction if needed

VS / Neurological assessment

Allow to rest

Corsetti


28/100


29/100

Sz - Client Education Medications:

Name, dosage, frequency

Take meds as prescribed

Do not miss dose What to do if it happens

Side effects

Avoid ETOH & excessive fatigue

Dont take any meds including OTCs MD knowledge

Corsetti


30/100


31/100

Meningitis

Corsetti


32/100

Meningitis

Inflammation of meninges

Two most common causes: Bacterial & Viral

Organism enters subarachnoid space Inflammation / WBCs respond

Exudates forms

Hydrocephalus / Cerebral edema

Increased ICP

Death if not treated

Corsetti


33/100

Bacterial Meningitis

Dx made by H & P

Confirmed by isolation of organism from CSF

LP essential part of work up

CSF findings: Cloudy

Pressure

Proteins

Glucose WBCs

Corsetti


34/100

Meningitis:Clinical Presentation

H/A, N/V

Back pain

Fever / Chills

Seizures Cloudy sensorium

Petichial rash

Nuchal rigidity

Brudzinski sign

Kernigs sign

Corsetti


35/100

Meningitis cont) Medical Rx

IV ATBX

Corticosteroids

Anticonvulsants

Analgesics

F & E

Corsetti


36/100

Meningitis-NSG ProcessAssessment

Subjective

H/A, muscle aches, nuchal rigidity, rash

Objective LOC

Pupillary reaction, eye movements

Motor response

Nuchal rigidity, Brudzinski & Kernig signs

Changes in attention, memory, personality

Corsetti


37/100

Meningitis - NSG Dxs Altered cerebral perfusion

Altered comfort: pain

Hyperthermia Risk for fluid volume deficit

Potential for injury

Corsetti


38/100

Meningitis - Management

NOC

Maintain cerebral perfusion

Provide comfort

Avoid hyperthermia

Maintain F & E balance

Prevent injury

Corsetti


39/100

Meningitis - Management

Frequent assessment

Monitor for complications

Administer atbx

Promote comfort

Infection control

Corsetti


40/100

Multiple Sclerosis

Corsetti


41/100

Multiple Sclerosis (MS)

Definition

Chronic,progressive, degenerative Ds affecting

myelin sheath and conduction pathway of CNS Pathophysiology

Inflammatory response thickens myelin

Damaged myelin removed Scar tissue formed

Impulses not transmitted as effectively

Corsetti


42/100

Multiple SclerosisEpidemiology

Prevalence:

Young adults / Female > males

Difficult to Dx initially

Symptoms vague & non lasting

Possible causes

Genetic, environmentalViral, immunological

Corsetti


43/100

Various Types of MSMost Common

Benign Few episodes / Mild attacks Minimal or no disability

Relapsing / Remitting (classic) Increasingly frequent attacks After exacerbation pt returns to baseline

Progressive / Relapsing No periods of remission

Progressive cumulative

Corsetti


44/100

Multiple SclerosisClinical Presentation

Motor

Fatigue

Stiffness

Spasms

Clonus

Babinski

Hyperactive DTRs

Dysarthria

Ataxia Tremors with

activity

Poor coordination

Muscle atrophy

Spasticity

Corsetti


45/100

Multiple SclerosisClinical Presentation (cont)

Visual

Loss of vision

Partial

Total

Blurred vision

Changes inperiph vision

Diplopia

Nystagmus Diorder affecting

any of the 3

mechanismsCorsetti

Multiple Sclerosis


46/100


Sensory

Pain, touch, temp

perception

Position &

vibratory sense

Numbness, tingling,

burning

B & B dysfunction

Frequency

Urgency

Incontinence

Constipation

Sexual dysfunction

Corsetti


47/100


Psychological /

Cognitive

Early: Anxiety

Apathy

Euphoria

Late:

Inattentiveness

Depression

Confusion

Memory loss

Corsetti


48/100

MSLabs/Diagnostic CSF

May have increased IgG bands

CT scan

May show density in white matter

Cerebral / Optic atrophy

MRI

Presence of plaque

Diagnostic for MS

EMG

Abnormalities in acute phase

Corsetti


49/100


50/100

MS Medical Rx Steroids (acute)

Side effects: Cause major problems with blood sugars

Immunocompromise

Give in the AM with FOOD.

Heart failurefluid retention

HTX

Electolyte imbalance

Psychosis

Antineoplastics (acute)

MTX

Cytoxan

Immunomodulators (long term) 1x day or 1x week

Avonex

Betaseron

Copaxone Corsetti


51/100

MS: Adjunctive Medical Rx Muscle Spasticity

Baclofen, Valium (problematic: long half-life)

Paresthesia (numbness and tingling) Tegretol (anticonvulsant) Neurontin (anticonvulsant) - Tricyclic antidepressants

Cerebellar ataxia Inderal Klonopin (highly addictive drug)

Bladder dysfunction (spastic bladder-can expel foley) Or atonic bladder

Urecholine (for contractions distention and retention)

, Ditropan (neurogenic bladder) Flomax

Do a cystogram to determine type of dysfunction and then they prescribe the appropriate medications.

Corsetti


52/100

MS AssessmentClinical manifestations are different

Subjective

Pts understanding of Ds &/or Rx

Presence of S &S of MS

Frequency & duration of exacerbation

Response to RX

Objective Physical exam

Diagnostic data

Corsetti


53/100

MS-most common: Possible Nsg Dxs

Impaired physical mobility

Self care deficit

Sensory/perceptual alteration

High risk for injury

Alteration in B & B functions

Body image disturbance

Altered skin integrity Many more..

Corsetti


54/100

MS-Possible Nsg Dxs

NOC Labels

Based on the particular Nsg Dx ie:

Mobility

Self care.

Corsetti


55/100

MS-NIC to Improve Mobility

Stretching exercises daily

Active / Passive ROM

Avoid fatigue / Frequent rest periods

Avoid rigorous activity

Avoid excess heat

Rest with exacerbation periods

Assistive devices Prevent / Manage problems of immobility

Corsetti

MS NIC to Prevent / Manage


56/100

MS-NIC to Prevent / Manage

B & B Complications

Avoid urinary retention

Adequate fluid intake

Bladder training

Suprapubic / foleychronic UTIs

Clock voiding every 1-2 hours

Hydration

Meds

Prevent constipation

Stress routine

Laxatives Corsetti


57/100


58/100

ALS)Amyotrophic Lateral Sclerosis

Corsetti


59/100

Amyotrophic Lateral SclerosisALS)

Also cAlled lou GehriGs dsProgressive / Degenerative Ds

Involves motor system

Paralysis & death most likely fromrespiratory failure

Usually w/in 2-5 yrs

Sensory & ANS not involved

Corsetti


60/100

ALS-Clinical Manifestations Progressive weakness of:

Shoulders / Neck / Trunk

Arms / Legs

Progressive difficulty with:

Swallowing

SpeakingBreathing

Corsetti


61/100

ALS- General NSG Interventions NSG interventions aimed at:

Maintaining respirations / Preventing aspiration

Preventing / Managing problems of immobility

Meeting nutritional needs

Promoting comfort

Providing emotional support

Corsetti


62/100

(GBS)Guillain Barre` Syndrome

Corsetti


63/100

Guillain Barre` Syndrome

Acute inflammatory disorder

Degeneration of peripheral nerve myelin sheath

? Autoimmune disorder

Often preceded by:

URI / GI infection / Viral infection / Vaccination

Three stages:

Initial period / Plateau period / Recovery

Corsetti


64/100

Types of GBS Ascending GBS- Most common

Symptoms begin in Lower Extremities & progress upward LOC, cerebral functions, pupillary reactions

Not affected

Pure motor GBS Similar to above except sensory component

Descending GBS Symptoms move from head to toe

Word finding difficultiessymptoms over 2-3 days. Most common and serious problem is resiratory distress and failure.

Corsetti


65/100

GBS-Clinical Manifestations Motor:

Muscle weakness / Paralysis

No atrophy

Or no DTRs **Respiratory compromise

Sensory:

Paresthesias

Pain

Corsetti


66/100


67/100

GBS Medical Rx Immunoglobulin

Plasmapheresis

Immunosuppressive

Drugs for symptomatic relief

Corsetti


68/100

GBS NSG Dxs Ineffective breathing

Impaired physical mobility

Anxiety / Powerlessness Self care deficits

Impaired communication

Altered comfort

Corsetti


69/100

GBS-Management

NOC / NIC aimed at:

**Maintaining respiration

*Avoiding complications of immobility

Promoting adequate nutrition

Maintaining communication

Relieving pain

Reducing anxiety

Corsetti

GBS


70/100

GBS

Management

Close monitoring of respiratory status May be on respirator

Monitor for / Prevent DVT / PE

ATC

TEDS / Sequential Compression Boots

Active & passive ROM

Mobilization Prevent complications of immobility

Corsetti


71/100

Myasthenia Gravis MG) Definition

Chronic Ds involving # & effectiveness of ACh @neuromuscular junction

Results

Impaired muscle contraction

Etiology

Believed autoimmune

Possible genetic factors

Thymus gland often abnormal

Strong association with hypothyroidism

Corsetti


72/100

MG-Clinical Manifestations Weakness and fatigue

Increases with exercise

Improves with rest

Ocular symptoms

**Ptosis

Weak & incomplete eye closure

Diplopia

Corsetti


73/100

MG-Clinical Manifestations cont)

Weakness of facial muscles Impaired chewing / Swallowing / Wt loss Slurred speech

Respiratory compromise Death if untreated

Posture Inability to hold head upright

Fatigue Weakness of limbs and trunk

Corsetti


74/100

MG - Diagnosis H & P

Tensilon test

EMG CXR / CT

TSH

Acetylcholine receptor antibodies (AchR)

Corsetti


75/100

MG Drug Rx Three groups:

Anticholinesterases

Corticosteroids

Immunosuppressant

Meds must be given on time

Monitor response

Side-effects of anticholinesterases mimicexacerbation of Ds

Corsetti


76/100

Cholinergic vsMyasthenic Crisis

1st

Due to:

Cholinesteraseinhibitor excess

Rx usually is

AtropineMay need vent

2nd

MG Exacerbation

Responds toanticholinesteras

e ie: Tensilon

Meds adjustedwith activity

Corsetti


77/100

MG: Triggering Factors

URI

Other infections

Anxiety / Stress

Menstruations

Pregnancy

Anesthesia / Surgery

Various meds

ETOH

Corsetti


78/100

MG NOC - NIC Focuses) Monitor respiratory status

Promote self care

Provide education

Rx / Side-effects

Assist with nutritional support

Provide eye protection

Corsetti


79/100

pArkinsons ds (pd) Movement disorder

ChronicProgressive

Degenerative Involves:

Basal gangliaSubstantia nigra

Corsetti

Normal physiology of


80/100

movements Basal ganglia stimulation

Inhibition of muscle tone

Refined, smooth movements

Process accomplished by: Balance of Dopamine & Acethylcholine (Ach)

Dopamine From substantia nigra

Inhibitory (blocks actions of Ach)

Ach From nerve endings

Excitatory

Corsetti


81/100

PD Pathophysiology Widespread substantia nigra

degeneration

Dopamine levels

Excessive excitation of selectedneurons by ACh

Inability to initiate movements

Loss of refined movements

Corsetti


82/100

Stages of PD Stage I

Very mild Ds

*Unilateral limb

involvementMinimal

weakness

Hand / Armtremors

Stage II

Mild Ds

Bilateral limbinvolvement

Mask-like facies

Slow shufflinggait

Corsetti


83/100

Stages of PD cont) Stage III

Moderate Ds

Significant gait

disturbance Generalized disability

Stage IV Severe Ds

Severe disability Akinesia

Rigidity

Stage V

End stage Ds

Completedependence

Corsetti


84/100

PD Key Features Posture

Stooped

Flexed trunk / Forward extension

Abducted / Flexed fingers Slightly dorsiflexed wrists

Gait Slow & shuffling

Short & hesitant steps

Propulsive / Difficulty stopping quickly

Corsetti


85/100

PD Key Features cont) Face

Mask-like facies

DroolingDifficulty chewing

& swallowing

Speech

Soft, low pitched

DysarthriaEcholalia

Corsetti


86/100

PD Key Features cont) Motor (cont)

Arms

Little swing

Tremors

Pill-rolling

Cog wheeling

Change in

handwritingGeneral

Bradykinesia

Akinesia Fatigue

Corsetti


87/100

PD Key Features cont) Autonomic

dysfunctions

Postural hypotension

Excess perspirations Oily skin

Seborrhea

Blepharospasms Constipation

Psychosocialimplications

Emotional labile

Depression

Paranoia

Mood swings

Delayed reactions

Cognitive impairment

Late in Ds

Corsetti


88/100

PD - Collaborative Management Drug Rx

Dopaminergic agents

Drug of choice by many

Carbidopa-levadopa (Sinemet) Amantadine (Symmetrel)

Anticholinergic agents

Decrease excitatory effects of ACh

Cogentin, Artane, Cogentin

Corsetti


89/100

PD Drug Rx cont) Dopamine agonists

Stimulate dopaminergic receptors

Parlodel

Mirapex

Permax Requip

COMT inhibitors

Block enzyme that inactivates dopamine

Comtan Tasmar

Corsetti


90/100

PD Non-Pharm Rx Surgery

Last resort

Stereotactic Pallidotomy

Thalamotomy

Deep Brain Stimulation

(DBS) Fetal tissue transplantation

Corsetti


91/100

PD Common NSG Dxs Impaired mobility

Risk for injury

Self care deficit

Impaired airway clearance Impaired communication

Altered nutrition

B & B dysfunction Ineffective coping..

Corsetti


92/100

PD NSG InterventionsGeneral)

Evaluate understanding of Ds / Rx Educate / Support client & family in long

term management of complications:

Immobility Infections

B & B problems

Malnutrition /Aspiration

Isolation / Depression / Stress

Corsetti


93/100

Alzheimers diseAse Ad) Characteristics:

Memory loss

Impaired judgment

Changes in personality Increasingly cognitive impairment

Severe physical deterioration

Death secondary to complications ofimmobility

Corsetti


94/100


95/100

Stages of ADStage I Mild Symptoms)

***Forgetfulness Mild memory loss

Short attention span

Decrease interest in personal affairs

Subtle changes in personality and behavior

Impaired ability to acquire new memories

LTM usually intact

Corsetti


96/100

Stages of AD cont)Stage II Moderate Symptoms)

Profound memory loss

***Confusion, difficulty with ADLs

Significant cognitive impairment Anomia / Agnosia / Apraxia / Aphasia

Severe loss of judgment

Abusiveness, agitation, paranoia

Insomnia ***Wandering, pacing

Corsetti

Stages of AD cont)


97/100

Stage III Severe Symptoms) Severe dementia

Profound impairment of all cognitivefunctions

Loss of speech

Loss of appetite / wgt loss

Loss of bladder and bowel control

Total dependence on caregiver

Corsetti


98/100

Diagnostic Criteria for Probable AD

Clinical presentation

Mental status testing

Confirmed by neuropsychological testing

Deficits in 2 or > cognitive areas: Memory, attention, language, personality, visuospatial

functions

Progressive Cognitive deterioration / No delirium

Ages 40-90

No systemic illnesses affecting brain

R/O other possible causes

Corsetti


99/100

AD Common NSG Dxs Altered thought process Risk for injury

Self care deficit

B & B dysfunction

Altered nutrition

Altered skin integrity

Many more.

Corsetti


100/100

AD General NSG Interventions Provide consistency Promote independence

Promote bowel and bladder continence

Assist with recognition of familiar faces

Promote communication

Prevent injuries

Provide family education

Documents

Neurological Dysfunction 2005 STUDENT COPY(1)