The Neurologic System

1. 22 Lecture Note PowerPoint Presentation The Neurologic System

2. LEARNING OUTCOME 1 Describe the components of the neurological system.

3. Neurological System • Central nervous system (CNS) • Brain • Spinal cord • Peripheral nervous system • Cranial nerves • Spinal nerves • Somatic nervous system • Autonomic nervous system • Reflex arc

4. Figure 22-1An illustration of the right hemisphere of the brain. In dark brown, the cerebellum. In beige, from bottom to top, the medulla oblongata and the pons. Just above it and slightly lighter, the corpus callosum.

5. LEARNING OUTCOME 2 Describe progressive dementias.

6. Dementia • Progressive disorder • Characterized by a loss of cognition and at least one of the following • Ability to speak coherently and understand language • Ability to recognize or identify objects • Ability to execute motor activities • Ability to think abstractly, make sound judgment, and plan and carry out complex tasks

7. Dementia • Aging is the greatest risk factor • Clinical diagnosis • Loss of intellectual ability with impairment that interferes with social or occupational functioning • Delirium has been ruled out

8. Dementia • Risk factors • Delirium • Mild cognitive impairment • Vascular dementia

9. Dementia • Types • Alzheimer’s disease (AD) • Abnormalities in the brain structure disrupts the health of neurons • Manifestations include memory failure, personality changes, and difficulty with ADLs • Causes • Genetics • Age • Gender • Race • Head injury • Environmental exposures

10. Dementia • Types • Vascular dementia • Abrupt onset of dementia • Focal neurological findings • Low-density areas indicate vascular changes in white matter • Multiple strokes in CT or MRI present • Unchanged personality • Emotional problem

11. Dementia • Types • Lewy body dementia • Clinical features persist over long period of time resulting in severe dementia • Lewy bodies and Lewy neuritis found in brain structures • Frontotemporal lobe dementia • Diagnosed based upon personality changes • Presence of frontal brain area atrophy in CT or MRI Lewy bodies : are abnormal aggregates of protein that develop inside nerve cells in Parkinson's disease (PD) and Alzheimer's disease (AD) and some other disorders.

12. LEARNING OUTCOME 3 Discuss the stages of Alzheimer’s disease and implications for nursing care.

13. AD • Progressive disorder • Results in the death of nerve cells • Memory failure • Personality changes • Increasing inability to manage activities of daily living

14. Figure 22-4Plaques and tangles: The hallmark of AD.

15. AD • Diagnosis • History • Physical examination • Neuropsychological testing • Definitive diagnosis: autopsy after death Autopsy : is a medical procedure that consists of a thorough examination of a body to determine the cause and manner of death and to evaluate any disease or injury that may be present

16. AD • Risk factors • Advancing age • Family history • Head trauma • Diabetes mellitus • Clinical depression

17. AD • Stages • Stage 1, Mild • Stage 2, Moderate • Stage 3, Severe

18. Nurse’s Role • Promote independence and autonomy • Prevent complications • Provide comfort • Promote quality of life • Education

19. Planning Care • No cure available • Goals of treatment • Slow progression • Manage manifestations • Caregiver experience needed • Long-term care • End-of-life care

20. Planning Care • Challenging behaviors and psychiatric symptoms develop in the AD patient • Settings used to care for AD patients • Individual’s home or family member’s home • Hospitals • Long-term-care facilities (nursing homes) • Congregate living facilities • Hospice settings

21. Pharmacological Interventions • Cholinesterase inhibitors • Slow progression of symptoms • Titrate dosages slowly • Donepezil (Aricept) • Rivastigmine (Exelon) • Galantamine (Reminyl)

22. Pharmacological Interventions • Memantine (Namenda) • N-methyl-d-aspartate (NMDA) antagonist • Alternative and complementary therapies • Vitamin E: limited support, more study needed • Nonsteroidal anti-inflammatory drugs/statins: patients taking these have reduced development of AD • Statins:are a class of drug used to lower cholesterol levels by inhibiting the enzyme HMG-CoA reductase.

23. Environmental Safety • Modify home to promote safety • Door locks • Secure rugs • Decrease water heater temperature • Handrails in bathroom

24. Functional Impairments • Utilize therapeutic nonverbal behaviors • Avoid fatigue, nonroutine activities, and alcohol • Avoid a high-stimulus environment • Prevent disability • Treat other conditions that lead to physical decline

25. Functional Impairments • Identify and respond rapidly to acute changes in function • Adapt care to accommodate neuromotor changes secondary to progression of dementia

26. Mood Disorders • Be alert for changes • Appetite • Disinterest • Anhedonia • Sleep abnormality • Fatigue

27. Delusions and Hallucinations • Cause • Delirium • Interaction of dementia and personality • Separate mental disorder coexisting with dementia • Disinhibition of cortical functions

28. Dependence in ADLs • Promote, preserve functional independence • Preventive plans of care

29. Inability to Initiate Meaningful Activities • Results in apathy or agitation for dementia sufferer • Promote social involvements

30. Anxiety • May be a primary disorder or a symptom of depression • May result from delusions, hallucinations, or functional impairment • Plan interventions to reduce stress, enhance feelings of trust and safety • Promote stability • Provide diversion activities

31. Spatial Disorientation • Results in incorrect interpretation of objects or directions • Results in fear, anxiety, suspicions, illusions, delusions, and safety concerns • Promote familiarity with environment • Use landmarks to provide “pop-up” cues

32. Elopement • A valid concern in individuals with cognitive impairments • Risk factors • Alzheimer’s Association Safe Return Program

33. Resistance to Care • Common in middle to late stages of dementia • Major reason for institutionalization and use of psychotropic medications and restraints • Management strategies • Restore calm • Time-out

34. Food Refusal • Occurs in each of the progressive stages of AD • Causes • Management interventions

35. Insomnia • Insomnia noted months prior to AD diagnosis • Establish routines to promote therapeutic sleep patterns • Establish sleep hygiene • Eliminate stimuli before bedtime

36. Apathy and Agitation • Associated with increasing cognitive decline • Escalation can result in violence and combative behaviors • Promote interest in the environment

37. Pharmacological Interventions • Used to promote comfort • Begin with lower dosages and gradually increase • Monitor side effects closely

38. Late Stage Issues • Institutionalization • Do not resuscitate decisions • Transfer to acute care facilities • Feeding tubes • Infections

39. LEARNING OUTCOME 4 Describe a contextual model to direct behavioral and pharmacological interventions for behavioral symptoms of Alzheimer’s disease.

40. A Contextual Model for Symptom Management for AD • Core = dementia + personality • Delusions – spatial disorientation = elopement + agitation • Hallucinations – functional impairment • Mood disorders – depression – anxiety + inability to initiate meaningful activities – apathy + repetitive vocalization + agitation + insomnia • Functional impairment – boredom – agitation

41. A Contextual Model for Symptom Management for AD • Processes at each level influence the next level • Four quadrants direct symptom management • Caregiving environment • Social environment • Physical environment • Medical treatment

42. A Contextual Model for Symptom Management for AD • Nurse-directed care • Approach focuses on prevention • Nurses provide and suggest behavioral strategies • Add pharmacological interventions as last resort

43. LEARNING OUTCOME 5 Discuss Parkinson disease in terms of diagnosis, treatment strategies, and nursing interventions.

44. Parkinson Disease • Cause • Loss of nerve cells • Decreased dopamine • Altered ratio of dopamine to acetylcholine • Exact cause unknown

45. Risk Factors • Aging • Equality noted between races and sexes • Genetics

46. Diagnostic Testing • No specific testing • Diagnosis made by excluding other possibilities

47. Characteristics of Parkinson Disease Stages • Early stage • One-sided symptoms • Changes in posture, walking, and facial expression • Middle stage • Difficulty rising from sitting position • Maintain a flexed posture • Late stage • Inability to stand or walk

48. Pharmacological Therapies • Sinemet • Anticholinergics • Amantadine • Dopamine agonists

49. Surgical Management • Unilateral posteroventral pallidotomy or thalamotomy • Brain stimulation surgery • Transplantation of fetal midbrain dopaminergic cells

50. Nursing Care • Promote mobility • Prevent falls • Preserve independence • Exercise