chapter 58 chronic neurologic problems fall...

Fall 2019 - Spring 2020

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Chronic Neurologic Problems Degenera4ve Neurologic Disorders

•  Mul$ple Sclerosis (MS) •  Parkinson’s Disease (PD) •  Myasthenia Gravis (MG) •  Amyotrophic Lateral Sclerosis (ALS)

Cogni$on Mobility Oxygena$on Safety Sensory Percep$on Stress and Coping *What concept is involved? *What nursing physical assessments are involved?

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Degenera$ve Neurologic Disorders •  Degenera$ve nerve diseases

lead to nerve damage that worsens as the disease progresses –chronic & progressive

•  Affect: balance, movement, speech, respiratory and cardiac func$on

•  Most have no cure and only symptom management

•  Impact on quality of life –onset in young/middle adult years

•  No definitive diagnostic test •  History & Physical Exam –

clinical manifesta$ons •  MRI of brain and spinal cord

may show presence of plaques, inflammation, atrophy, and tissue breakdown and destruction*

•  Damage or an attack occurring at different times (usually >1 month apart)*

•  All other possible diagnoses must have been ruled out*

*MS


Multiple Sclerosis


Altera4on Descrip4on Manifesta4ons Interven4ons and Therapies

Mul$ple Sclerosis

Autoimmune disease that causes damage to the myelin sheath around nerves •  Cause: unknown •  Possible factors include: infection, smoking, physical injury, emotional stress, excessive fatigue, pregnancy, poor state of health

•  Genetic component

•  Loss of balance •  Muscle spasms •  Numbness or $ngling

•  Problems moving arms or legs

•  Tremor or weakness in arms or legs

•  Bowel and bladder problems

•  Eye, hearing, speech problems

•  Cogni$ve deficits

•  Pharmacologic therapy to slow the progression of disease and decrease severity of aWacks

•  Physical therapy •  Speech therapy •  Assis$ve devices for mobility •  Health lifestyle (nutri$on, ac$vity, rest)

•  Safety measures to prevent falls

•  Counseling


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Multiple Sclerosis

•  Immune cells aWack the myelin sheath around nerves cells, causing decreased transmission of nervous signals

•  Impairs the brain’s ability to communicate with the rest of the body resul$ng in a variety of symptoms

Fall 2019 - Spring 2020 Symptom a)acks vary in loca2on and severity, las2ng for days, weeks, or months

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Mul4ple Sclerosis –Mul4system Effects

Think –what is the priority nursing “concept” and “interven$on” for each system affected?


What are secondary symptoms (result from prolonged primary symptoms) and ter2ary symptoms (psychosocial complica2ons)?

Mul$ple Sclerosis –Mul$system Effects E4ology Clinical Manifesta4ons Clinical Therapies

Primary symptoms (result from demyelina$on)

•  Sensory disturbances (visual, hearing, speech, balance, pain)

•  Motor disturbances (weakness, paresthesias, bowel and bladder dysfunc$on, unsteady gait, spas$city, breathing problems)

•  Cogni$ve dysfunc$on (concentra$on, memory, reasoning, judgment, depression)

•  Disease modifying therapies •  Symptom-‐specific medica$ons •  Cor$costeroids to treat exacerba$ons •  Assis$ve devices •  Physical therapy or rehabilita$on

Secondary symptoms (result from prolonged primary symptoms)

•  Pressure injuries •  Osteoporosis •  Aspira$on pneumonia •  UTIs •  Back or hip pain •  Muscle atrophy, poor postural

alignment •  Bone fractures

•  An$bio$cs •  Analgesics •  Biphosphonates •  Physical therapy •  Immobiliza$on of fractures •  Nutri$on and fluids

Ter$ary symptoms (psychosocial complica$ons)

•  Social problems (partner, family, friends, social isola$on)

•  Voca$on problems (loss of job, loss of transporta$on)

•  Emo$onal problems (depression, irritability, hopelessness)

•  Psychologic counseling •  An$depressants •  Referral to home care, transporta$on

assistance •  Encouragement to engage in social

interac$on •  Pa$ent teaching to minimize isola$on •  Caregiver support •  Voca$onal rehabilita$on Fall 2019 - Spring 2020 6


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Mul4ple Sclerosis –Drug Therapy

Other Drug Therapy: •  Muscle relaxants •  CNS stimulants •  Anticholinergics •  Tricyclic

antidepressants Selective potassium channel blocker

•  Antiseizure drugs *Recall Musculoskeletal


•  Currently no cure for MS •  Drug therapy used to slow progression of disease includes use of: –  Immunosuppressants –  Immunomodulators –disease modifying drugs

– Adrenocorticotropic hormone

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Mul4ple Sclerosis –Interprofessional Care

Planning: •  Maximize

neuromuscular function

•  Maintain independence in activities of daily living for as long as possible

•  Manage disabling fatigue

•  Optimize psychosocial well-‐being

•  Adjust to the illness •  ↓ Factors that

precipitate exacerbations


Implementa$on: •  Help patient identify triggers

and develop ways to avoid them or minimize their effects

•  Assist patient in dealing with anxiety and grief caused by diagnosis

•  During acute exacerbation, prevent major complications of immobility

•  Focus teaching on building general resistance to illness –  Avoid fatigue, extremes of hot and cold, exposure to infection

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Mul4ple Sclerosis –Interprofessional Care

Teaching: •  Good balance of exercise and rest •  Relieve spasticity •  Improve coordination •  Train patient to substitute unaffected

muscles for impaired muscles •  Minimize caffeine intake •  Nutritious, well-‐balanced meals

–  Increase fiber if constipated •  Treatment regimen

–  Management of medications •  Self-‐catheterization if necessary •  Adequate intake of fiber to aid in

regular bowel habits •  Emotional adjustments •  Lifestyle changes

Expected Outcomes: •  Maintain or improve

muscle strength and mobility

•  Use assistive devices appropriately for ambulation and mobility

•  Maintain urinary continence

•  Make decisions about lifestyle modifications to manage MS



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Parkinson’s Disease

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Parkinson’s Disease

A motor system disorder caused by the loss of dopamine neurons •  Cause: unknown •  Environmental factors and genetic make-‐up

•  Secondary parkinsonism: exposure to chemicals, drugs,

•  Others (hydrocephalus,hypoparathyroidism, infections, stroke, tumor, trauma)

•  Tremor in the hands, arms, legs, jaw, and face

•  Rigidity and stiffness of the limbs and trunk

________________ •  Bradykinesia (slowness of movement)

•  Impaired balance and coordination

•  Lack of affect •  Slurred speech

•  Pharmacologic therapy to manage symptoms

•  Deep brain s$mula$on (DBS) •  Health lifestyle

_________________________

•  Walking carefully •  Occupa$onal therapy •  Ac$vi$es to improve balance

Parkinson’s Disease •  Loss of dopaminergic

neurons and Lewy bodies (abnormal aggregates of proteins) result in abnormal nerve-‐firing patterns that cause impaired movement

•  Dopamine and acetylcholine must be balanced to produce smooth movement. When dopamine neurons are degenerated, acetylcholine signaling is increased, causing an imbalance

Fall 2019 - Spring 2020 11 Tremor Rigidity Akinesia Postural instability = TRAP

Parkinson’s Disease –Multisystem Effects •  Lower limb and trunk motor

deficits •  Upper limb motor deficits •  Head and neck motor

deficits Non-‐motor symptoms: •  Cogni$ve effects •  Emo$onal effects •  Sleep problems •  Bowel and bladder effects •  Other:

•  Sexual dysfunc$on •  Orthosta$c hypotension •  Pain •  Seborrhea •  Hyperhidrosis •  Anosmia

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How will this affect your ability to provide quality nursing care?


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You see M.J. at your outpatient clinic with a cough and fever. It is obvious that his Parkinson’s disease has advanced. During your assessment of him, what clinical manifestations would you expect to find? a.  Slurred speech, visual disturbances, and ataxia. b.  Muscle atrophy, spasticity, and speech difficulties. c.  Muscle weakness, double vision, and reports of fatigue. d.  Drooling, stooped posture, tremors, and a propulsive gait.

Fall 2019 - Spring 2020 13

Audience Response Ques$on

Parkinson’s Disease –Complications

•  Dysphagia may result in malnutrition or aspiration

•  General debilitation may lead to pneumonia, UTIs, and skin breakdown

•  Orthostatic hypotension –  ↑ Risk for falls and injuries

Critical Thinking: •  If a patient is in the later stages of

Parkinson’s disease, what do you anticipate as the care required to maintain functioning of all body systems (ADLs)?

↑ as disease progresses Motor symptoms Weakness Akinesia Neurologic problems Neuropsychiatric problems Dementia often results and associated with ↑ mortality

Fall 2019 - Spring 2020 14

Parkinson’s Disease –Drug Therapy

•  Use of only one drug is preferred due to: •  Fewer side effects •  Dosages are

easier to adjust •  Combination therapy

is often required as disease progresses

•  Excessive dopaminergic drugs can lead to paradoxic intoxication = aggravation, rather than relief of symptoms


•  No cure for PD •  Drug therapy aimed at correcting imbalances of neurotransmitters within the CNS and reduce severity of symptoms include use of: – Levodopa with carbidopa (Sinemet) –primary treatment

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Parkinson’s Disease –Interprofessional Care

Surgical therapy: •  Deep brain

stimulation (DBS)

•  Ablation – Destruction

•  Transplantation


Nutritional Therapy: •  Malnutrition and constipation

can be serious consequences •  Patients with dysphagia and

bradykinesia need food that is easily chewed and swallowed

•  Adequate fiber •  Eating more numerous small

meals is less exhausting than eating fewer large meals each day

•  Provide ample time to avoid frustration

•  Levodopa can be impaired by protein and vitamin B6 ingestion

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Planning: •  Maximize neurologic

function •  Maintain independence

in activities of daily living (ADLs) for as long as possible

•  Optimize psychosocial well-‐being


Implementa$on: •  PD is a chronic degenerative disorder with no acute exacerbations

•  Focus teaching and nursing care – Maintenance of good health – Encouragement of independence

– Avoidance of complications such as contractures and falls

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Expected Outcomes: •  Perform physical

exercise to deter muscle atrophy and joint contractures

•  Use assistive devices appropriately for ambulation and mobility

•  Maintain nutritional intake adequate for metabolic needs

•  Experience safe passage of fluids and/or solids from mouth to stomach

•  Use methods of communication that meet needs for interaction with others


Teaching: •  Physical exercise and

a well-‐balanced diet •  Problems secondary to bradykinesia

can be alleviated by –  Consciously thinking about stepping

over a line on the floor –  Lifting toes when stepping –  One step back and . . .two steps forward

•  Manage sleep problems •  Get out of a chair by using arms and

placing the back legs on small blocks •  Remove rugs and excess furniture •  Simplify clothing from buttons and

hooks •  Use elevated toilet seats •  Use an ottoman to elevate legs •  Caregivers may experience stress

associated with disease progression (i.e., dementia)

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Audience Response Ques$on What is an appropriate nursing diagnosis for M.J. at this stage of advanced Parkinson’s disease (drooling, stooped posture, tremors, and a propulsive gait)? a.  Risk for injury related to limited vision b.  Risk for aspiration related to impaired swallowing c.  Urge incontinence related to effects of drug therapy d.  Ineffective breathing pattern related to diaphragm fatigue

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Myasthenia Gravis

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Myasthenia Gravis Autoimmune disease that aWacks acetylcholine receptors, preven$ng molecules from aWaching to and s$mula$ng muscle contrac$ons Thymus gland –thymic hyperplasia

•  Fluctua$ng weakness of skeletal muscles

•  Muscles that move eyes, eyelids, chew, swallow, speak, and breathe

•  No sensory loss, reflexes are normal, muscle atrophy rare

•  Myasthenia Crisis: muscle weakness in areas of swallowing and breathing -‐respiratory

•  Pharmacologic therapy to enhance transmission of impulses

•  Surgical therapy •  Plasmapheresis and IV immunoglobulin G for symptom management

Myasthenia Gravis

•  Fluctua$ng weakness of certain skeletal muscle groups

•  These muscles are generally stronger in the morning and become exhausted with con$nued ac$vity

Fall 2019 - Spring 2020 21


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Myasthenia Gravis –Interprofessional Care Drug therapy:

– An$cholinesterase drugs (Pyridos$gmine –Mes$non)

– Cor$costeroids (Prednisone) –  Immunosuppressant

Other: – Plasmapheresis –  IV immunoglobulin G

Surgical therapy: – Removal of thymus gland –thymectomy

Nursing Assessment: Strength of affected body parts, fa$gue, RR, depth, O2 sat, ABG, pulmonary func$on test Planning: •  Return of normal muscle

endurance •  Manage fa$gue •  Avoid complica$ons •  Maintain quality of life Evalua4on: •  Op$mal muscle func$on •  Free from side effects of

drug •  No complica$ons •  Maintain quality of life

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Myasthenia Gravis –Interprofessional Care Nursing Implementa4on:

•  Adequate ven$la$on •  Nutri$on therapy to prevent aspira$on

•  Schedule medica$ons for peak effec$veness

•  Prevent fa$gue •  Teach adherence to medical regimen, complica$ons of disease, drug therapy

•  What are 2 reasons the pa$ent with MG is admiWed to the hospital? 1. 2.

•  What is the nursing focused assessment?

•  What type of diet will be ordered?

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Amyotrophic Lateral Sclerosis

Fall 2019 - Spring 2020 24


Amyotrophic Lateral Sclerosis (ALS)

Progressive neuromuscular disorder characterized by loss of motor neurons in brainstem and spinal cord for unknown reason

•  Progressive muscle weakness (tripping, dropping things, abnormal fa$gue of extremi$es)

•  Slurred speech •  Muscle cramps and

twitches •  Does not affect

intellect

•  No cure •  Pharmacologic therapy to slow the

progression of disease •  Discuss Advance Direc$ves


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Amyotrophic Lateral Sclerosis •  Dead motor neurons

cannot produce or transport signals to muscles

•  Electrical and chemical messages origina$ng in brain do not reach muscles to ac$vate them

•  Usually leads to death 2-‐5 years aier diagnosis –  Lou Gehrig’s disease, Stephen Hawking

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Amyotrophic Lateral Sclerosis –Interprofessional Care

Nursing implementa$on: •  Moderate intensity, endurance type exercises for trunk and limbs

•  Facilita$ng communica$on •  Reduce risk of aspira$on •  Early iden$fica$on of respiratory insufficiency

•  Decrease pain •  Decrease risk of injury •  Diversional ac$vi$es •  Support of cogni$ve and emo$onal func$ons

•  No cure •  Death occurs from

respiratory tract infec$ons

•  Cogni$vely intact, while was$ng away

Fall 2019 - Spring 2020 26

chapter 58 chronic neurologic problems fall...

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