(1) Definition--a slowly progressive,
degenerative C.N.S. disorder; symptoms can be controlled to an extent
and for a limited time with drug therapy, but there is no cure and
the condition gets progressively worse
(2) Incidence and Etiology--occurs
mainly after 50 and in both sexes equally, mostly idiopathic in
nature
(3) Patho: injury or impairment of
dopamine-producing cells in the substantia nigra in the midbrain;
when dopamine decreases, the ability to refine voluntary
movement is lost; there is now an imbalance and acetylcholine is
increased in proportion to dopamine; this causes a problem with
controlling and initiating voluntary movement in signs
and symptoms of rigidity, bradykinesia and tremor(see
text).
(4) Stages 1 through 5 have been
identified(see text)
(5) Diagnostics: none specific; rule out
other neuro diseases
(6) Assessment Findings:
1. HISTORY: MED REVIEW, EXPOSURE TO
CHEMICALS, INFECTIONS
2. INSPECTION: FLAT AFFECT, DROOLING,
OILY SKIN, EXCESS PERSPIRATION, STOOPED POSTURE, TREMORS, SHUFFLING
GAIT WITH LACK OF ARM SWINGING AND POSSIBLE ATAXIA
3. PHYSICAL EXAM: MAY HAVE ORTHOSTATIC
HYPOTENSION, WEIGHT LOSS, BLURRED VISION OR IMPAIRED UPWARD GAZE,
RIGIDITY--"COGWHEELING", DIMINISHED MUSCLE STRENGTH, REFLEXES
HYPERACTIVE OR DIFFICULT TO ELICIT DUE TO TREMORS OR RIGIDITY,
DIFFICULTY WITH PHONATION; INCREASING DIFFICULTY PERFORMING ADLS (DO
FUNCTIONAL ASSESSMENT
4. PSYCHOLOGICAL EXAM: POSSIBLE
DEPRESSION OR DEMENTIA--(DO MENTAL STATUS EXAM)
(7) Nursing Diagnoses:
a. IMPAIRED PHYSICAL MOBILITY
R/T
b. ALTERED NUTRITION
R/T
c. SELF CARE DEFICIT
R/T
d. BODY IMAGE DISTURBANCE
R/T
(8) Management: Goal: to increase levels
of dopamine, reduce symptoms and improve functioning
(a) Pharmacologic Therapy--drug
choice depends on stage and major
manifestations:
1.
Carbidopa/Levodopa(Sinemet)--available
in rations of 1:4 or 1:10; dose is titrated individually; best to use
lowest effective dose possible; used when significant disability is
present
2.
Selegiline(Eldepryl)--often
given as initial therapy for mild disability; research has shown that
this drug retards progression of disease; in later stages of the
disease, given with Sinemet when there is a poor response to Sinemet
alone; usual dose is 10 mg. daily
Rationale: increased
dopaminergic activity
Side effects: similar to
Sinemet
3.
Anticholinergics primarily to
relieve tremor:
Benztropine(Cogentin)
Trihexphenidyl(Artane)
Rationale: Block excitatory
activity of Acetylcholine
Side effects: confusion,
delirium, urinary retention, palpitations, drug
fever
4.
Ergot Alkaloids or Dopamine
Agonists: can be used early in
disease or in later stages when poor response to levodopa
occurs:
Bromocriptine(Parlodel)
Pergolide(Permax)
Rationale: activates
dopamine
Side effects: similar to
Sinemet
5.
Antiviral drug: Amantadine(Symmetrel)
(b). Non Pharmacologic
Therapies:
1. Experimental surgeries--brain
grafting with adrenal tissue and embryonic
tissue
2. P.T., O.T., Speech therapy,
psychotherapy for depression
(9) Nursing Care--according to stage and
level of disability
1. PREVENT PROBLEMS OF IMMOBILITY
SUCH AS CONSTIPATION, SKIN BREAKDOWN, RESPIRATORY INFECTIONS AND
CONTRACTURES--HELP PATIENT WITH AMBULATION, EXERCISE PROGRAM, GIVE
MEDS ON TIME AND AS DIRECTED
2. ASSIST PATIENT WITH MAINTENANCE OF
INDEPENDENCE IN ADLS--FOLLOW THROUGH WITH O.T. AND P.T.
PRESCRIPTIONS
3. ASSESS FOR NUTRITIONAL STATUS AND
PROVIDE FOODS THAT ARE EASIER TO CHEW AND SWALLOW; MONITOR WEIGHT;
TIME MEDS TO PEAK AT MEAL TIMES AND GIVE SUPPLEMENTS AS
NEEDED
4. SUPPORT SELF ESTEEM AND ASSESS FOR
DEPRESSION
5. TEACH THERAPEUTIC AND SIDE EFFECTS
OF MEDS
6. PROVIDE FOR HOME HEALTH CARE AS
INDICATED
7. REFER TO COMMUNITY RESOURCES AS
NECESSARY SUCH AS AMERICAN PARKINSON'S DISEASE
ASSOCIATION
A. Definition--chronic inflammatory disease
causing demyelination and scarring of neurons characterized by
remissions and exacerbations
B. Incidence and Etiology: More
affluent,caucasian women between ages of 20-50 who live in cold
climates; has genetic predisposition and thought to be
autoimmune(possibly triggered by viral infection).
C. Key features: look in text--note
"CHARCOT'S TRIAD"
D. Diagnostics:IgG elevated in spinal
fluid; MRI or contrast CT scans--plaques can be visualized as well as
ventricular enlargement
E. Assessment Findings:
(1) History: onset and duration of
changes in vision, motor skills, bladder bowel, and sexual
functioning, sensation, pattern(periodically get better?), aggravated
by ?, family history of M.S.
(2) Physical Exam: do complete
neurological assessment
VISION--MAY SEE DECREASED VISUAL
ACUITY, SCOTOMAS, NYSTAGMUS
HEARING--HEARING LOSS, TINNITUS,
VERTIGO
SPEECH--DYSARTHRIA; SCANNING
SPEECH(SLOW ENUNCIATION AND HESITATION)
EXTREMITIES--INTENTION TREMOR, POOR
COORDINATION, UNSTEADY GAIT, MUSCLE WEAKNESS, SPASMS OR
SPASTICITY, HYPERACTIVE DTRS WITH CLONUS, POSITIVE BABINSKI'S,
HYPALGESIA
(3) Psychosocial History:
changes in behavior and judgment, mood
swings
F. Nursing Diagnoses:
IMPAIRED PHYSICAL MOBILITY R/T
CHANGES IN VISION, MOTOR FUNCTION, AND SENSATION
BODY IMAGE DISTURBANCE R/T LOSS OF
INDEPENDENCE
PAIN R/T MUSCLE SPASM
HIGH RISK FOR INFECTION R/T URINARY
RETENTION AND /OR IMMUNOSUPPRESSIVE THERAPY
G. Management: Goal: Reduce symptoms and
improve functioning
(1)
Pharmacologic:
(a)
Immunosuppressive Drugs like
ACTH or
chemotherapy
(b)
Antispasmodics
to relieve pain from spasms
like Baclofen(Lioresal) or
Diazepan(Valium)
(c)
Carbamazepine(Tegretol) or
Tricyclic antidepressants likeAmitriptyline(Elavil)
to relieve painful paresthesias
(d)
Amantadine
for chronic fatigue
(5)
Imipramine(Tofranil) or
Bethanecol(Urecholine) to
stimulate urination; urinary antiseptic drugs to suppress bacteria
(6)
Stool
softeners for
constipation
(2) Non
pharmacologic:
(a) Therapies such as O.T.,
P.T., speech, etc.
(b) Psychotherapy for emotional
dysfunction
H. Nursing Care--depending on severity
of condition--similar to pts. with Parkinson's Disease with a few
special considerations:
ALLEVIATE PAIN AND MONITOR FOR
INFECTION
PREVENT INJURY RELATED TO LOSS OF OR
ALTERED SENSATION
TEACH PATIENT TO GET PLENTY OF REST
AND AVOID STRESS AND SITUATIONS THAT ARE UPSETTING
ALTERNATE PATCHING EYES EVERY FEW
HOURS MAY HELP WITH DIPLOPIA
MAY NEED REFERRAL TO LONG TERM CARE
LATE IN COURSE OF DISEASE
2.
Brain Attack (Stroke or Cerebrovascular Vascular
Accident):
A. Three main etiologies: thrombotic,
embolic, hemorrhagic(ICH or SAH--Intracerebral Hemorrhage or
Subarachnoid Hemorrhage)
B. Sites for Brain Attack pathology:
carotid arteries(anterior circulation), vertebral-basilar
system(posterior circulation), middle cerebral artery(MCA) in
cerebral cortex(hemispheric stroke), Lacunar--small, deep
arteries
C. Phases: T.I.A.(precursor of C.V.A.),
R.I.N.D.(Reversible Ischemic Neurologic Deficits),
Stroke-in-Evolution or Completed stroke
D. Signs & Symptoms: depends on
etiology, site of origin and area of brain; may be generalized or
focal or both
E. Left Brain Injury vs. Right Brain
Injury--different profile of deficits(review)
F. Diagnostics:
LAB--CBC, SED RATE, COAGULATION
PROFILE, BLOOD CHEMISTRY
EKG, ECHO OR HOLTER
MONITOR
CT OR MRI SCANS
CAROTID DOPPLER OR
ULTRASOUND
CEREBRAL
ARTERIOGRAPHY
G. Assessment Findings:
(1) History: onset, worsening or
improvement of deficits, question about risk factors, medication
history
(2) Physical: on Mental Status and
neurological assessment, pt. may be disoriented with altered level of
consciousness, visual field cuts(amaurosis fugax or hemianopsia),
cranial nerve dysfunction, speech, articulation, and swallowing
problems, carotid bruits, heart murmurs, high blood pressure or
orthostatic changes in blood pressure--check both arms--irregular
apical pulse or asymmetrical peripheral pulses, altered pattern of
respiration, one-sided motor weakness or flaccidity or changes in
sensation, or bladder or bowel dysfunction
(3) Psychosocial: Assess reaction to
stroke--denial? memory loss? behavior pattern--impulsive and euphoric
with poor judgment or slow, depressed and anxious? Is emotional
lability present? What are patient's financial status and living
arrangements?
H. Nursing Diagnoses:
(1) Altered cerebral tissue perfusion
r/t disruption of blood flow or edema
(2) Sensory/Perceptual Alterations r/t
neuro deficits such as unilateral neglect or
hemianopsia
(3) Impaired communication r/t damage to
speech and language areas
(4) High risk for aspiration r/t
impaired swallowing
(5) Altered Nutrition, less than body
requirements, r/t impaired swallowing
(6) Impaired Physical Mobility r/t
cognitive, motor and sensory deficits
(7) Depression r/t change in body image
and sense of helplessness
(8) High risk for injury r/t neuro
deficits
I. Management:(Two approaches:
surgical/non-surgical and acute/rehab)
(1)
Surgical--if
patient is candidate for surgery according to condition, cause of
stroke and extent of pathology, then Carotid Endarterectomy may be
performed to remove atheromatous plaque obstructing vessel; only done
in selected cases when carotid is 70% or more obstructed; if cause of
stroke is leaking or ruptured aneurysm, Craniotomy for aneurysm
repair may be needed depending on Grade of Aneurysm(see text for
grading scale).
(2)
Medical--depends on type and
cause of neurologic event:
(a)
T.I.A.--preventative
therapy for thrombotic stroke with antiplatelet drugs such as
aspirin, 80-325mg daily or Ticlopidine(Ticlid) 250mg bid for ASA
intolerance; if T.I.A. is cardiac in origin, treat cause and
anticoagulant therapy may be instituted with Coumadin; teach to
modify lifestyle
(b)
Completed Stroke(C.V.A.): Has
acute phase and rehab. phase:
1.
ACUTE PHASE TREATMENT:
ICU--STABILIZE WITH:
OXYGEN
THERAPY OR MECHANICAL
VENTILATION
DRUGS AND EQUIPMENT
TO MONITOR AND CONTROL BLOOD
PRESSURE AND CARDIAC
STATUS
HYPOTHERMIA
FOR UNCONTROLLED FEVER
PLACEMENT OF N/G TUBE, FOLEY
CATHETER
SEIZURE
PRECAUTIONS AND
ANTICONVULSANTS IF INDICATED
PROPER POSITIONING TO
PREVENT ASPIRATION OR
INJURY
FLUID AND ELECTROLYTE
SOLUTIONS THROUGH CENTRAL LINE
OBSERVE FOR AND
CONTROL INCREASED INTRACRANIAL
PRESSURE
INSTITUTE
ANTICOAGULANT
THERAPY ACCORDING TO PROTOCOLS
IF THROMBOTIC OR EMBOLIC STROKE WITH
THROMBOLYTICS(t-PA OR
STREPTOKINASE) WITHIN THE FIRST 3 HOURS OR CONTINUOUS
HEPARINTHERAPY
IF STROKE RESULT OF SAH OR
ICH, CALCIUM CHANNEL BLOCKERS (NIMOTOP) TO
PREVENT
VASOSPASM AROUND INJURED AREA
OF BRAIN AND SEDATION TO
PREVENT FURTHER BLEEDING
2.
REHABILITATIVE PHASE: WHENCONDITION STABLE:
INITIAL
EVALUATION FOR REHAB.
STATUS
TEAM APPROACH
WITH MANY THERAPIES INVOLVED
SUCH AS O.T., P.T., SPEECH THERAPY, DIETITIAN, PHARMACIST,
VOCATIONAL, SOCIAL WORK CONSULT FOR FINANCIAL AND LONG TERM CARE
PLACEMENT; NURSING COORDINATES CARE AND CARRIES OUT NURSING AND
TEAM ORDERS ON A 24 HOUR BASIS
J. Nursing Interventions and Care of the
Stroke Patient:
(1) Maintain open airway and adequate
O2 supply to brain--position on side with HOB elevated;
monitor O2 sats, suction as necessary; turn frequently and
assess for adventitious breath sounds
(2) Monitor for increased intracranial
pressure(ICP)--do neuro checks or Glasgow Coma Scale q 1-2 hrs. or as
ordered; report signs of deterioration immediately(see appropriate
charts and care plan in chapter); reorient patient
frequently
(3) Prevent complications of
immobility--position so as to minimize contractures and edema of
affected extremities and institute measures to prevent
DVT
(4) Aid the client in compensating for
neurological deficits--teach patient to touch, dress and care for
both sides of body if unilateral neglect is present and turn head to
compensate for visual field cuts; in collaboration with O.T., guide
patient with perceptual defects in performing ADLs; approach from
unaffected side
(5) Prevent injury by monitoring for
cranial nerve deficits like diminished corneal reflex or gag and
swallowing reflexes--use of eye patches or artificial tears; give
thickened liquids that are easier to swallow--coordinate with speech
therapy and dietitian; also, institute seizure precautions in the
acute phase, and assist patient with transfers and ambulation in the
rehab phase in conjunction with P.T.
(6) Administer drugs as
ordered--anticoagulants with goal to achieve 1.5 to 2 times the
client's normal baseline PTT or PT for therapeutic effect--monitor
for bleeding; antiplatelet drugs, antihypertensives, calcium channel
blockers, anticonvulsants or sedatives may be ordered depending on
the etiology of the stroke syndrome.
(7) Assist with communication when
aphasia present--coordinate efforts with speech pathologist depending
on type of aphasia(receptive or expressive)
(8) Provide optimal nutritional and
fluid intake for the patient--collaborate with speech therapist for
swallowing evaluation and with dietitian
(9) Develop a bladder and bowel training
program until the client's normal function or pattern
returns
(10) Provide emotional support for
client and family in meeting the crisis of sudden
disability
(11) Prepare for surgery if
necessary
K. Discharge Planning: The client will
be discharged to home with visiting nurses, to a rehab unit for
further training or to long term care as needed; the nurse
collaborates with the social worker and home health agency, teaches
the client and family about medications, ensures that the home is
prepared with appropriate assistive devices and counsels patient and
family about resources to call for non-emergency and emergency
situations.
A. Vascular headaches--due to sequential
changes affecting intracranial and extracranial arteries; first
vasoconstriction causes brain ischemia, then vasodilation causes
throbbing pain
1.
Types:
MIGRAINE
WITH OR WITHOUT AURA(CLASSIC OR COMMON)
CLUSTER
HYPERTENSIVE--ONLY IN PATIENTS
WITH VERY SEVERE OR EPISODIC HYPERTENSION
CEREBRAL ANEURYSM OR
SAH--OFTEN VERY SUDDEN AND
SEVERE ACCOMPANIED BY NUCHAL RIGIDITY AND
PHOTOPHOBIA
INCREASED INTRACRANIAL
PRESSURE--PATTERN IS THAT IT
IS WORSE IN THE MORNING AND IMPROVES AS PATIENT IS UP AND WALKING
AROUND; AGGRAVATED BY COUGHING, SNEEZING, BENDING OVER OR
STRAINING; NOT RELIEVED BY USUAL
ANALGESICS
2.
Management:
MIGRAINE--DRUGS:
PREVENTION: CALCIUM CHANNEL
BLOCKERS LIKE PROCARDIA, CARDIZEM; BETA BLOCKERS LIKE INDEROL;
TRICYCLIC ANTIDEPRESSANTS LIKE ELAVIL OR DOXEPIN; NSAIDS;
ERGOTAMINE TARTRATE; ONE ASPIRIN DAILY; METHYSERGIDE
MALEATE(SANSERT) FOR SEVERE, INTRACTABLE
H/A
ACUTE OR ABORTIVE THERAPY:
SUMATRIPTAN SUCCINATE
(IMITREX--DRUG OF CHOICE) INJECTED SC OR TAKEN ORALLY,OR
ERGOTAMINE TARTRATE OR DIHYDROERGOTAMINE MESYLATE(D.H.E. 45) I.M.
OR I.V. IN HOSPITAL ACCOMPANIED BY REGLAN FOR THE NAUSEA WHICH
ACCOMPANIES THIS MEDICATION; REST IN DARKENED ROOM. IMITREX IS
CONTRAINDICATED IN PATIENTS WITH ANGINA BECAUSE OF POTENTIAL
CORONARY VASOSPASM
TEACHING:
AVOID TRIGGER FACTORS SUCH AS CHOCOLATE, ALCOHOL, MSG, CAFFEINE,
ESTROGEN, FOODS WITH TYRAMINE; LONG PERIODS OF SLEEP; LEARN STRESS
MANAGEMENT, BIOFEEDBACK, RELAXATION
TECHNIQUES
CLUSTER--PROPHYLACTIC
THERAPY: SANSERT, INDOCIN,
PREDNISONE OR LITHIUM CARBONATE (SEE
TEXT).
ACUTE OR ABORTIVE THERAPY:
ERGOTAMINE TARTRATE, SL; D.H.E. 45; OXYGEN THERAPY FOR 5 TO 15
MINUTES
TEACHING:
INSTRUCT PT. TO WEAR
SUNGLASSES AND AVOID LIGHT AND GLARE DURING ATTACKS; TO PREVENT
ATTACKS, AVOID TRIGGERING SITUATIONS SUCH AS ANGRY OUTBURSTS,
EXCESSIVE EXERCISE AND EXCITEMENT
Neurological Disorders 
