Chapter 44

Care of Patients with Problems of the Central Nervous System: The Brain

Mrs. Marion Kreisel MSN, RNNU230 Adult Health 2Fall 2011

Headaches

• Migraine headache—chronic, episodic disorder with multiple subtypes

• Stages:• Prodrome: pt has specific symptoms such as food

cravings or mood changes• Aura phase: visual changes, flashing lights, or diplopia• Headache phase: few hours to a few days• Termination Phase: intensity of headache decreases• Postrodrome: fatigues, irritable, and has muscle pain

Interventions

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

Drug Therapy

• Abortive therapy—alleviating pain during the early aura phase or soon after the headache has started

• Preventive therapy

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

Cluster Headache

• Histamine cephalalgia• Cause unknown; attributed to vasoreactivity and

oxyhemoglobin desaturation• Unilateral, radiating to forehead, temple, or cheek• Ipsilateral (same side) tearing of the eye,

rhinorrhea, ptosis (drooping of eye lid), and miosis (contraction of eye pupil)

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

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

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)

Types of Seizures

• Generalized seizures• Partial seizures• Unclassified seizures

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

Seizures Risks

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

Nonsurgical Management

• Antiepileptic drugs (AEDs)• Importance of compliance• Health teaching

Seizure Precautions

• Oxygen • Suction equipment• Airway• IV access• Siderails up• No tongue blades

Seizure Management

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

Acute Seizure Management Anticonvulsants

• Lorazepam (Ativan)• Diazepam (Valium)• Diastat (form of valium)• IV phenytoin (dilatin) or fosphenytoin (Cerebyx)

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

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

• Do not administer warfarin with phenytoin.• Document and report side and adverse effects.

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.• Alternative employment may be needed.• Vocational rehabilitation may be subsidized.

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 into the

patient’s mouth during a seizure.

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.

Surgical Management

• Vagal nerve stimulation (VNS)• Conventional surgical procedures• Anterior temporal lobe resection• Partial corpus callosotomy treats tonic clonic

movments. Surgically resects 2/3 of the corpus callosum to decrease repaid firing

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

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

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

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

Encephalitis

• Inflammation of the brain tissue and surrounding meninges

• Caused by viral agents: Can be life threatening or lead to persistent neurologic problems as learning disabilities, epilepsy, memory and fine motor deficits. Bacteria, fungi, or parasites

• Degeneration of neurons of the cortex• Hemorrhage, edema, necrosis, small lacunae

develop in cerebral hemispheres

Hemorrhagic Encephalitis

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

Parkinson Disease

• Progressive neurodegenerative disease that is the third most common neurologic disorder of older adults

• Tremor, rigidity, bradykinesia (slow movemnet), or akinesia (no movement)

• Dopamine inhibits the function of excitatory neurons allowing control over voluntary movement

Parkinson Disease masklike facial expressions

Wide openFixed staring eyes

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

Drug Therapy in Parkinson Disease

Dopamine agonists: mimic dopamine stimulating receptors in the brain (apomorphine (Apokyn), pramipexole ( Miraprex)

Catechol O-methyltransferases (COMTs) are enzymes that imactivate dopamine and prolong levodopa ex. Entacapone (Comtan)

Monoamine oxidase type B (MAO-B) inhibitorsDopamine receptor antagonists (mesylate (Azilect)

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.

Management of Parkinson Disease

• Exercise and ambulation, improve mobility (yoga, exercise late morning, look down when getting out of chairs etc.)

• Self-management• Injury prevention• Nutrition• Communication• Psychosocial support

Management of Parkinson Disease (Cont’d)

• Surgical management includes:• Stereotactic pallidotomy/thalamotomy• Deep brain stimulation• Fetal tissue transplantation

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

Structural Changes in the Brain

• Alzheimer’s disease creates changes that include:• Neurofibrillary tangles: Tangled mass of fibroid

tissue in brain• Neuritic plaques: degenerativenerve terminals

inrease beta amyloid.• Vascular degeneration: loss of nerve cel to

regenerate properally• Changes in neurotransmitters• Increased amounts of an abnormal protein,

beta amyloid

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

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.

Interventions

• Orientation and validation therapy. Orientation therapy for early stages of AD and validation therapy for late chronic stages of AD.

• KNOW PAGE 975• Promote self-management.• Promote bowel and bladder continence.• Assist with facial recognition.• Promote communication.

Drug Therapy PG 976

• Donepezil, galantamine, rivastigmine• Memantine• Antidepressants• Psychotropic drugs

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

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

• Restraints should be a last resort. If restraints applied know all nursing considerations

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.

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.

Disturbed Sleep Pattern (Cont’d)

• Adjust treatment and medication schedule to provide for uninterrupted sleep.

• Give mild antianxiety agent or hypnotic.

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 (rapid jerky movemnets) movements in the limbs, trunk, and facial muscles

• Three stages, each lasting about 5 years over an average 15 years of the disease

Management of Huntington Disease

• No known cure or treatment• Genetic counseling• Antipsychotic agents or monoamine-depleting

agents used to manage movement abnormalities that are disabling or interfere with ADLs

• Medications to treat depression, anxiety, and obsessive-compulsive behaviors

NCLEX TIME

Question 1

What is a priority nursing intervention for a 53-year-old woman with new onset of severe headaches with photophobia?

A. Management of associated nausea and vomitingB. Identification of triggers that cause headaches C. Evaluation and education of cardiovascular and stroke signs and

symptoms D. Effective pain management

Question 2

What is the primary expected outcome for a patient with

Parkinson disease?

A. Progressive difficulty with mobilityB. Severe dementiaC. MalnutritionD. Difficulty with effective communication

Question 3

What percentage of people in the United States can

control their seizures with medication?

A. 20%B. 40%C. 60%D. 80%

Question 4

The older patient states that he has recently noted changes in his

cognition and worries he is developing Alzheimer’s disease. The

nurse suspects the patient is not experiencing Alzheimer’s

symptoms because he:

A. Is also experiencing hallucinations B. Has only mild memory lossC. Has recently been placed on a medication regimen

that could affect cognition D. Is not experiencing changes in his eyesight

Question 5

Alzheimer’s disease accounts for what percentage of

the dementias occurring in people older than 65 years?

A. 20%B. 40% C. 60% D. 80%