Chapter 44

1. Chapter 44 Care of Patients with Problems of the Central Nervous System: The Brain

2. Headaches • Migraine headache—chronic, episodic disorder with multiple subtypes • Stages: • Prodrome • Aura phase • Headache phase

3. Interventions • Recognize migraine symptoms • Respond and see health care provider • Relieve pain and associated symptoms

4. Drug Therapy • Abortive therapy—alleviating pain during the early aura phase or soon after the headache has started • Preventive therapy

5. Complementary and Alternative Therapies • Yoga, meditation, massage, exercise, biofeedback, relaxation techniques • Acupuncture • Use of herbs and nutritional therapies with approval • Avoidance of trigger events that may result in migraine episodes, such as tension and stress

6. Cluster Headache • Histamine cephalalgia • Cause unknown; attributed to vasoreactivity and oxyhemoglobin desaturation • Unilateral, radiating to forehead, temple, or cheek • Ipsilateral tearing of the eye, rhinorrhea, ptosis, and miosis

7. Therapy • Same types of drugs used for migraines • Patient to wear sunglasses and avoid sunlight • Oxygen via mask • Avoidance of precipitating factors, such as anger, excitement • Surgical management

8. Tension Headache • Neck and shoulder muscle tenderness and bilateral pain at the base of the skull and in the forehead • 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

9. 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 behavior • 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)

10. Types of Seizures • Generalized seizures • Partial seizures • Unclassified seizures

11. Types • 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

12. Seizures Risks • Seizures may result from: • Metabolic disorders • Acute alcohol withdrawal • Electrolyte disturbances • Heart disease • High fever • Stroke • Substance abuse

13. Nonsurgical Management • Antiepileptic drugs (AEDs) • Importance of compliance • Health teaching

14. Seizure Precautions • Oxygen • Suction equipment • Airway • IV access • Siderails up • No tongue blades

15. Seizure Management • Will depend on the type of seizure • Observation and documentation • Patient safety • Side-lying position • No restraints

16. Acute Seizure Management • Lorazepam • Diazepam • Diastat • IV phenytoin or fosphenytoin

17. Status Epilepticus • Medical emergency • Prolonged seizures lasting more than 5 minutes or repeated seizures over the course of 30 minutes • Establish an airway • ABGs • IV push lorazepam, diazepam; rectal diazepam • Loading dose IV phenytoin

18. Drug Therapy • Evaluate most current blood level of medication, if appropriate. • Be aware of drug-drug and drug-food interactions. • Maintain therapeutic blood levels for maximal effectiveness.

19. Drug Therapy (Cont’d) • Do not administer warfarin with phenytoin. • Document and report side and adverse effects.

20. 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.

21. Patient and Family Education (Cont’d) • Alternative employment may be needed. • Vocational rehabilitation may be subsidized.

22. 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 intothe patient’s mouth during a seizure.

23. 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.

24. Surgical Management • Vagal nerve stimulation (VNS) • Conventional surgical procedures • Anterior temporal lobe resection • Partial corpus callosotomy

25. Meningitis • 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

26. Physical Assessment and Clinical Manifestations • 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

27. Laboratory Assessment of Meningitis • Cerebrospinal fluid analysis • Computed tomography scan • Blood cultures • Counterimmunoelectrophoresis • Polymerase chain reaction • Complete blood count • X-ray study to determine presence of infection

28. Drug Therapy • Broad-spectrum antibiotic • Hyperosmolar agents • Anticonvulsants • Steroids (controversial) • Prophylaxis treatment for those who have been in close contact with the meningitis-infected patient

29. Encephalitis • Inflammation of the brain tissue and surrounding meninges • Caused by viral agents, bacteria, fungi, or parasites • Degeneration of neurons of the cortex • Hemorrhage, edema, necrosis, small lacunae develop in cerebral hemispheres

30. Hemorrhagic Encephalitis

31. Interventions • 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

32. Parkinson Disease • Progressive neurodegenerative disease that is the third most common neurologic disorder of older adults • Tremor, rigidity, bradykinesia, or akinesia • Dopamine

33. Parkinson Disease (Cont’d)

34. Assessment • Fatigue, slight tremor, problems with manual dexterity • Rigidity, changes in facial expression, uncontrolled drooling, dementia, changes in voluntary movement, excessive perspiration, orthostatic hypotension • No specific diagnostic tests

35. Drug Therapy in Parkinson Disease Dopamine agonists Catechol O-methyltransferases (COMTs) Monoamine oxidase type B (MAO-B) inhibitors Dopamine receptor antagonists

36. 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 administration. • Take “drug holiday,” especially in the use of levodopa therapy.

37. Management of Parkinson Disease • Exercise and ambulation • Self-management • Injury prevention • Nutrition • Communication • Psychosocial support

38. Management of Parkinson Disease(Cont’d) • Surgical management includes: • Stereotactic pallidotomy/thalamotomy • Deep brain stimulation • Fetal tissue transplantation

39. 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 immobility

40. Structural Changes in the Brain • Alzheimer’s disease creates changes that include: • Neurofibrillary tangles • Neuritic plaques • Vascular degeneration • Changes in neurotransmitters • Increased amounts of an abnormal protein, beta amyloid

41. Manifestations • Changes in cognition • Alterations in communication and language abilities • Changes in behavior, personality, and judgment • Changes in self-care skills • Psychosocial assessment, especially patient’s reaction to changes in routine

42. Interventions in Alzheimer’s Disease • Answer patient’s questions truthfully. • Assess and treat other medical problems. • Provide cognitive stimulation and memory training. • Structure the environment to increase patient’s ability to function. • Prevent overstimulation.

43. Interventions • Orientation and validation therapy. • Promote self-management. • Promote bowel and bladder continence. • Assist with facial recognition. • Promote communication.

44. Drug Therapy • Donepezil, galantamine, rivastigmine • Memantine • Antidepressants • Psychotropic drugs

45. 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 activities

46. 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

47. 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.

48. 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.

49. Disturbed Sleep Pattern (Cont’d) • Adjust treatment and medication schedule to provide for uninterrupted sleep. • Give mild antianxiety agent or hypnotic.

50. Huntington Disease • Hereditary disorder transmitted as an autosomal dominant trait at the time of conception • Movement disorder characterized by both neurologic and behavioral symptoms • Gradual clinical onset of progressive mental status changes, leading to dementia and choreiform movements in the limbs, trunk, and facial muscles • Three stages, each lasting about 5 years over an average 15 years of the disease