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Tuesday, September 18, 2007

Peripheral Neurological Disorders & Central Nervous Center

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Peripheral Neurological Disorders & Central Nervous Center Slideshow Transcript

Slide 1: Peripheral Neurological Disorders MG, GB

Slide 2: Common Nursing Diagnoses(there are more…) Mobility, Impaired Physical  Self Care Deficit  Disturbed Self Esteem  Fatigue  Respiratory Function, risk for impaired  Risk for Injury  Pain 

Slide 3: Myasthenia Gravis: “grave muscle weakness” Affects about one of every 7,500  people, all ethnic groups affected Onset usually between age 20 to 40 for  women. Later age of onset tends to include more men.

Slide 4: Pathophysiology Autoimmune response: decreases the number  of available acetylcholine receptors at the nerve to muscle junction. Antibodies bind to the receptor sites, render them useless. Without Ach receptors there is muscle weakness. Frequently goes with Thymus abnormalities 

Slide 5: Symptoms of MG: gradual onset common Weakness in muscles needed to talk,  chew, swallow. Ptosis  Drooling  Later, limb weakness, respiratory  muscle weakness

Slide 6: High Risk Nursing Care Issues Choking and/or aspiration during eating  and drinking Insufficient breathing effort due to  muscle weakness leads to respiratory crisis Falling 

Slide 7: Diagnosis of Myasthenia Gravis H & P: for signs and symptoms of muscle  weakness, patterns MRI or CT of Thymus  Labwork: look for increased antibody levels in  blood Tensilon Test. Tensilon is a short acting  anticholinesterase inhibitor. Give to patient, if see dramatic but short lived improvement in symptoms, + for MG. When physician is doing test, have atropine available.

Slide 8: Myasthenic Crisis Patient with MG can present with a severe  bout of symptoms, especially respiratory— may present like anxiety. Prevention involves taking care re  precipitants: menses, pregnancy (read in Lewis), stress, infection, over-exertion. Since overmedication can also cause  problems (cholinergic crisis), differentiate carefully.

Slide 9: Treatment with Medication Anticholinesterase drugs: inhibit the  destruction of acetylcholine and thus make more acetlycholine available at receptor sites. Two common ones are Prostigmin  (neostigmine) and Mestinon (pyridostigmine). Best taken about an hour prior to meals.  Also use prednisone (decrease inflammatory  response), other immunosuppressants, plasmapheresis, thymectomy

Slide 10: Guillain-Barre’ Syndrome Acute inflammatory process with  varying degrees of motor weakness and paralysis Immune system destroys the myelin  sheath – affects cranial, motor, and sensory neurons

Slide 11: Epidemiology 0.4-1.7 cases per 100,000  Affects all races and ages, but more  often seen among those over 45 and Caucasian

Slide 12: Symptoms of GB Flaccid paralysis with absent reflexes  Respiratory weakness/failure  Pain and paresthesias  Facial weakness with double vision and  trouble speaking

Slide 13: Respiratory Care

Slide 14: Medications

Slide 15: Other nursing care issues

Slide 19: Unit 8 CNS Problems: Read about Headaches and treatment  Read about Huntingtons Disease and  treatment Read about different types of Seizures  In this unit we will discuss Parkinson  Disease, Alzheimer’s Disease, MS, and SCI in class

Slide 20: Multiple Sclerosis: “Many areas of patchy destruction” About 250,000 to 300,000 people with  MS in the USA. More common among those living in the North, Caucasian descent. Typical onset is in young and middle  adult years.

Slide 21: Destruction of Myelin Sheath

Slide 22: MS Symptoms: Early and Later Early: Nystagmus, diplopia, blurry vision, mild  weakness, poor sensation, paresthesias. Pattern is quite variable, which makes diagnosis difficult Middle/Later: More serious weakness of  limbs, and can include paralysis, spasticity, ataxia. Numbness/tingling worsened. Continued eye, ear problems. Bowel and Bladder function may be affected  Emotionally difficult disease, Labile mood. 

Slide 23: Diagnosis of MS is Difficult No definitive test for MS  H & P remains central  MRI – look for plaques on neurons  Evoked potential study  CSF analysis, labwork 

Slide 24: Medical Treatment of MS: medication therapy Bethanecol  Glucocorticoids  Immunosuppressants  Skeletal muscle relaxants, eg Baclofen  and Dantrolene

Slide 25: MS: Multiple Nursing Care Issues Help the client avoid triggers to  exacerbation and to moderate activity level Later, immobility becomes a real issue,  and the complications of immobility require vigilant care Read your text re care plan. 

Slide 26: Assessment of seizure activity Observe, time and document carefully  Body movements, character, type  progression, include eye movements Loss of consciousness, incontinence  Precipitating factors you note  Post seizure (ictal) response. Confusion,  sleepiness common.

Slide 27: Issues in Seizure Precautions Tongue blade is outdated  Suction equipment nearby, IV or hep. lock if  risk is high for venous access Padding on bedrails/Observe client often  Avoid precipitants  Notify MD of new seizure, injury, unrelenting  seizure activity If client seizes, move objects away, side lying  if possible, loosen tight clothing, ease to floor or bed if possible

Slide 28: Status Epilepticus Defined as seizure over 4 minutes or in rapid  succession Life threatening due to brain damage mainly  Response involves ABC’s, IV administration  of anticonvulsants in a particular order. Usually valium first, if no response, dilantin and later a third drug are used. NG to control vomitus possibly. Review Anticonvulsant drugs discussed earlier 

Slide 29: Parkinson’s Disease: Triad 1. Tremor: hands, feet, steady rate,  resting, “pill rolling” 2. Rigidity: stiffening up, cogwheeling  3. Bradykinesia: less movement inc.  trunk, masklike face, moving “en bloc” and festinating gait (shuffling with accelerations)

Slide 30: More Parkinson’s Symptoms Decreased volume and variability of  voice Micrographia  Depression 50%  Dementia 10-40%  Psychosis 10%  Chronic, progressive disease 

Slide 31: Pathophysiology Pathway for disposing of flawed  proteins (Uch-Ll) is disturbed, leading to neuron death in substantia nigra. There is less dopamine available, symptoms don’t occur until about 80% destroyed. Gene on chromosome 4 is implicated in  the disease

Slide 32: Nursing Care of PD FASE: avoid fatigue, anxiety,  stimulation, and exertion Multiple care issues: injury prevention,  self care, nutrition, dysphagia, activity and rest, mobility, communication deficit, despair/grief, altered thought process, and knowledge deficit

Slide 33: Surgical Treatment of PD Pallidotomy: globus pallidus (which is  overactive in PD) is partly ablated—SE is occasional speech impairment Electronic Stimulator placement: Small  wire is set into brain and has a device placed in chest wall that can be stimulated to control increased tremors

Slide 34: Meds for Parkinson’s D. Levodopa—the precursor to dopamine  This drug chemically reverses the effect of  PD, enhances amt. of dopamine SE: nausea, hypotension, agitation and  hallucinations After several years, efficacy may decline  Don’t take with B-6 or if you have narrow  angle glaucoma

Slide 35: Sinemet: levodopa and carbidopa Adding carbidopa to levodopa allows  smaller dose of levodopa and fewer side effects Carbidopa prevents the breakdown of  levodopa When taking: have LFTs, RFTs, CBC  Many meds reverse the effect:  antipsychotics, dilantin, reserpine

Slide 36: Selegiline: Eldepryl MAOB inhibitor: decreases the  degradation of dopamine (note similarity to MAOIs) Careful use: many serious interactions  (opiods, SSRI’s, TCA’s) Limit tyramine rich foods in diet (You  will need to get familiar with list)

Slide 37: Other meds in PD Tasmar Mirapex   TCA’s Requip   Antihistamines For test know   sinemet, eldepryl Symmetrel  and be aware of Parlodel  others Pergolide 

Slide 38: Dementia: Basic Definitions Progressive deterioration in intellectual  functioning – MEMORY, LEARNING, and JUDGEMENT Onset insidious, chronic, and may be a  primary disorder

Slide 39: Types of Dementias-some Alzheimers DAT—see pathophys.  Picks; prominent emotional disinhibition  Huntington’s Chorea: inherited,  choreiform movement plus confusion Infarct Dementias  Korsakoffs slow starvation of brain  tissue ass. W/ alcoholism HIV encephalopathy 

Slide 40: Pathophysiology of DAT

Slide 41: Progression of Alzheimer’s Stage I: mild—forgetful. Short term memory loss,  aware of problem, depression common Stage II: moderate—confused. Progressive memory  deficits, Instrumental ADL’s decline, Cover with confabulation, denial Stage III: Severe—ambulatory dementia. Thinking and  communicating decrease, all ADLs decrease, depression resolves, person not aware of deficits Stage IV: Late. Loss of basic human abilities, identity  of self and family gone, physical deterioration

Slide 42: Treatment of Alzheimers Recent advances—correlation with head  trauma, disuse, large families 3 genes cause over production of alpha  beta Some possible protective factors-  vitamin E, antiinflammatory drugs, estrogen supp. Med: Tacrine/Cognex 

Slide 43: Nursing Diagnosis (some) Confusion, acute and chronic  Caregiver role strain  Memory, impaired  Wandering 

Slide 44: Spinal Cord Injury Epidemiology About 10-12,000 new cases per year, has  stayed stable over past 20 years. 80% male/20% female; 60% are young adult  males Currently about ¼ million paralyzed  individuals in the US Most frequent causes: MVA, gunshot (17%),  falls, diving, skiing, contact sport 50% paraplegia; 50% quadriplegia 

Slide 45: Pathophysiology Injury leads to:  lactate and chemical release causing vasospasm edema, hemorrhage All within a closed space: decreased circulation (decreased O2/glucose), build up of lactic acid

Slide 46: More Patho By limiting compression and edema, cell  death is minimized This can affect the level of injury.  Even a small gain in level of injury, can  mean the preservation of function of a group of muscles that can directly affect rehabilitation

Slide 47: Shock in SC Injury: acute period Spinal Shock Neurogenic shock   Flaccid paralysis  High level of injury  No bowel or bladder  hypotension, no persp. tone bradycardia No reflex activity  peripheral vasodilation Poikelothermia  NSG: dopamine, atropine, NSG: keep temp WNL,  MAST boots, tilt table, foley catheter, IV fluids, gradual position change Skin care, positioning, bowel regimen (suppositories)

Slide 48: When Spinal and Neurogenic shock subsides Typically see improvement in shock  symptoms after 1-6 weeks. Note: see spasticity, spastic bladder  Stabilization of VS.  A small percentage of clients continue  to have “flaccid” paralysis

Slide 49: Some treatment issues in acute period Time is important. Medical   CNS tissue does not management with survive for long. methylprednisone, Stabilization of spine mannitol, meds to  on site stabilize BP Techniques for CPR  Surgical  –jaw thrust decompression and Transfer to neuro  fixation/stabilization center asap

Slide 50: Nursing Issues: Acute period Spinal / Neurogenic shock  Altered respiratory function  Prevent DVT, skin breakdown and other  complications of immobility Body alignment  Post op infection risk 

Slide 51: Levels of Spinal Cord Innervation C-4 to C-6 Phrenic Nerve: diaphragm  function Upper Limbs C-7, C-8  T-1 to T-6 Intercostal muscles  T-1to L-4 Sympathetic outflow (HR,  bronchiole dilation, temp control) Bowel and Bladder at lowest level 

Slide 52: Autonomic Dysreflexia (also called hyperreflexia) Excess reflex arc stimulation, which fails to be  modified by messages from the brain, leads to a crisis. Sky high BP with bradycardia, headache,  sweating, blurred vision Can result in a CVA  NSG: raise HOB, Monitor VS, give  antihypertensive if needed, eliminate source of excess reflex activity such as kinked catheter, full bowel, etc.

Slide 53: More Notes about Nursing Issues: Enduring Problems Depression and suicide are common  About ¼ patients have chronic pain and  spasticity (antispasmodics) About 1/10 patients have decubiti  Altered respiratory function at higher  levels of injury is a continued concern- aspiration, atelectasis

Slide 54: Nursing Care Concerns Triple logroll technique to maintain  body alignment Skeletal/halo traction and care: pin  care, skin care under brace, proper fit Read in text re level of injury and  related ability and rehab potential



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