NUR 205 Ch 46 Nursing Management: Patients with Neurologic Disorders

Parkinson's Disease: Clinical Manifestations & Assessment (Postural Disturbances)

- A loss of postural reflexes occurs, & pt stands w/ the head bent forward & walks w/ a propulsive gait - The posture is caused by the forward flexion of the neck, hips, knees, & elbows - Pt may walk faster & faster, trying to move the feet forward under the body's center of gravity (shuffling gait) - Difficulty in pivoting that causes loss of balance places pt at risk for falls

Medical & Nursing Management: During a Seizure

- A major responsibility of the nurse is to observe & record the sequence of signs; Before & during a seizure, pt is assessed & the following items are documented: (1) The circumstances before the seizure (visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; hyperventilation) (2) The occurrence of an aura (a premonitory or warning sensation that can be visual, auditory, gustatory, or olfactory) that is experienced at the beginning of a seizure & remembered (3) The 1st thing pt does in the seizure—in what part of the body the movement or stiffness begins, conjugate gaze position (termed that denotes both eyes working in unison), & the position of the head at the beginning of the seizure--This info gives clues to the location of the seizure origin in the brain (In recording, it is important to state whether the beginning of the seizure was observed) (4) The type of movements in the part of the body involved (5) The areas of the body involved (turn back bedding to expose pt) (6) The size of both pupils & whether the eyes are open (7) Whether the eyes or head are/is turned to one side (8) The presence or absence of automatisms (involuntary motor activity, like lip smacking or repeated swallowing) (9) Incontinence of urine or stool (10) Duration of each phase of the seizure (11) Unconsciousness, if present, & its duration (12) Any obvious paralysis or weakness of arms or legs after the seizure (13) Inability to speak after the seizure (14) Movements at the end of the seizure (15) Whether or not pt sleeps afterward (16) Cognitive status (confused or not confused) after the seizure - In addition to providing data about the seizure, nursing care is directed at preventing injury & supporting pt, physically & psychologically

Parkinson's Disease: Medical & Nursing Management (Improving Mobility)

- A progressive program of daily exercise will increase muscle strength, improve coordination & dexterity, reduce muscular rigidity, & prevent contractures that occur when muscles are not used--Walking, riding a stationary bicycle, swimming, & gardening are all exercises that help maintain joint mobility; Stretching (stretch-hold-relax) & ROM exercises promote joint flexibility; Postural exercises are important to counter the tendency of the head & neck to be drawn forward & down - A PT may be helpful in developing an individualized exercise program & can provide instruction to pt & caregiver on exercising safely; Faithful adherence to an exercise & walking program helps to delay the progress of the disease - Warm baths & massage, in addition to passive & active exercises, help relax muscles & relieve painful muscle spasms that accompany rigidity - Balance may be adversely affected b/c of the rigidity of the arms (arm swinging is necessary in normal walking); Special walking techniques must be learned to offset the shuffling gait & the tendency to lean forward - Pt is taught to concentrate on walking erect, to watch the horizon, & to use a wide-based gait (e.g. walking w/ feet separated); A conscious effort must be made to swing the arms, raise the feet while walking, & use a heel-toe placement of the feet w/ long strides - Pt is advised to practice walking to marching music or to the sound of a ticking metronome, b/c this provides sensory reinforcement; Breathing exercises while walking helps to move the rib cage & to aerate parts of the lungs; Frequent rest periods aid in preventing frustration & fatigue

Alzheimer's Disease: Medical & Nursing Management (Promoting Physical Safety)

- A safe home environment allows pt to move about as freely as possible & relieves the family of constant worry about safety - To prevent falls & other injuries, all obvious hazards are removed & hand rails are installed; A hazard-free environment allows pt maximum independence & a sense of autonomy - Adequate lighting, esp in halls, stairs, & bathrooms, is necessary; Night lights are helpful, particularly if pt has increased confusion at night (sundowning) - Driving is prohibited, & smoking is allowed only w/ supervision; Pt may have a short attn span & be forgetful; Wandering behavior can often be reduced by gentle persuasion or distraction - Restraints should be avoided, b/c they increase agitation; Doors leading from the house must be secured; Outside the home, all activities must be supervised to protect pt, & pt should wear an ID bracelet or neck chain in case he/she becomes separated from the caregiver

Alzheimer's Disease (AD)

- AD: a progressive, irreversible, degenerative neurologic disease that begins insidiously & is characterized by gradual losses of cognitive function & disturbances in behavior & affect - Can occur as young as 40, but is uncommon before 65 - 2 types: familial, or early onset AD, & sporadic, or late-onset AD - Familial is rare & occurs in middle-age (if at least 1 relative had AD, there is a familial component) - Sporadic occur in people older than 65 & has no obvious patter of inheritance

Medical & Nursing Management: After a Seizure

- After a pt has a seizure, nurse's role is to document the events leading to & occurring during & after the seizure & to prevent complications (e.g. aspiration, injury) - Pt is at risk for hypoxia, vomiting, & pulmonary aspiration; To prevent complications, pt is placed in side-lying position to facilitate drainage of oral secretions, & suctioning is performed, if needed, to maintain a patent airway & prevent aspiration - Seizure precautions are maintained, including having available functioning suction equipment w/ a suction catheter & oral airway; Bed is placed in a low position w/ 2 to 3 side rails up & padded, if necessary, to prevent injury to pt - Pt may be drowsy & may wish to sleep after the seizure; he/ she may not remember events leading up to the seizure & for a short time thereafter

Parkinson's Disease: Clinical Manifestations & Assessment (Akinesia/ Bradykinesia)

- Akinesia means a lack of movement, & bradykinesia means a slowness of initiation & execution of movement - Pts may take longer to complete activities & have difficulty initiating movement, like rising from a sitting position or turning in bed

Myasthenia Gravis: Nursing Management

- B/c MG is a chronic disease & most pts are seen on an outpatient basis, much of the nursing care focuses on pt & family teaching; Educational topics for outpatient self-care include med management, energy conservation, strategies to help w/ ocular manifestations, & prevention & management of complications - Med management is a crucial component of ongoing care; Understanding the actions of the meds & taking them on schedule is emphasized, as are the consequences of delaying medication & the s/s of myasthenic & cholinergic crises; Pt can determine the best times for daily dosing by keeping a diary to determine fluctuation of sx's & to learn when the med is wearing off--Med schedule can then be manipulated to maximize strength throughout the day ***Maintenance of stable blood lvls of anticholinesterase meds is imperative to stabilize muscle strength; Therefore, the anticholinesterase meds must be administered on time; Any delay in admin of meds may exacerbate muscle weakness & make it impossible for the pt to take meds orally - To minimize the risk of aspiration, mealtimes should coincide w/ the peak effects of anti cholinesterase med; Rest before meals is also encouraged, to reduce muscle fatigue; Pt is advised to sit upright during meals, w/ the neck slightly flexed to facilitate swallowing; Soft foods in gravy or sauces can be swallowed more easily; if choking occurs frequently, nurse can suggest puréed food w/ a pudding-like consistency - Suction should be available at home, w/ pt & family instructed in its use; Supplemental feedings may be necessary in some pts to ensure adequate nutrition - Impaired vision results from ptosis of 1 or both eyelids, decreased eye movement, or double vision; To prevent corneal damage when the eyelids don't close completely, many providers may instruct pt to tape or patch the eyes closed for short intervals & to regularly instill artificial tears; If taping is done, it is important to ensure the lid covers the eye to prevent corneal abrasion from the tape or patch; Pts who wear eyeglasses can have "crutches" attached to help lift the eyelids; Patching of 1 eye can help w/ double vision - Pt is reminded of the importance of maintaining health promotion practices & of following health care screening recommendations; Factors that exacerbate sx's & potentially cause crisis should be noted & avoided (emotional stress; infections, particularly respiratory infections; vigorous physical activity; some meds; & high environmental temp - Pt is also taught strategies to conserve energy; To do this, nurse helps pt identify the optimal times for rest throughout the day; If pt lives in a 2-story home, nurse can suggest that frequently used items be kept on each floor to minimize travel b/w floors; Pt is encouraged to apply for a handicapped license plate to minimize walking from parking spaces, & to schedule activities to coincide w/ peak energy & strength lvls - Pts are encouraged to wear a medical alert bracelet identifying them as having MG

Alzheimer's Disease: Medical & Nursing Management (Supporting Cognitive Function)

- B/c dementia of any type is degenerative & progressive, pts display a decline in cognitive function over time - In the early phase of dementia, minimal cueing & guidance may be all that are needed for pt to function fairly independently for a # of yrs--However, as pt's cognitive ability declines, family members must provide more & more assistance & supervision - A calm, predictable environment helps people w/ AD interpret their surroundings & activities; Environmental stimuli are limited, & a regular routine is established; A quiet, pleasant manner of speaking, clear & simple explanations, & use of memory aids & cues help minimize confusion & disorientation & give pts a sense of security - Prominently displayed clocks & calendars may enhance orientation to time; Color-coding the doorway may help pts who have difficulty locating their room; Active participation may help pts maintain cognitive, functional, & social interaction abilities for a longer period

Guillian- Barre Syndrome: Medical & Nursing Management (Improving Communication)

- B/c of paralysis, pt can't talk, laugh, or cry & therefore has no method for communicating needs or expressing emotion - Establishing some form of communication w/ picture cards or an eye blink system provides a means of communication - Collaboration w/ the ST may be helpful in developing a communication mechanism that is most effective for a specific pt

Guillian- Barre Syndrome: Medical & Nursing Management

- B/c of the possibility of rapid progression & neuromuscular respiratory failure, GBS is a MEDICAL EMERGENCY, requiring management in an ICU - After baseline values are identified, assessment of changes in muscle strength & respiratory function alert the clinician to the physical & respiratory needs of the pt -Respiratory therapy or mechanical ventilation may be necessary to support pulmonary function & adequate oxygenation; Some clinicians recommend elective intubation before the onset of extreme respiratory muscle fatigue; Mechanical ventilation may be required for an extended period - Pt is weaned from mechanical ventilation after the respiratory muscles can again support spontaneous respiration & maintain adequate tissue oxygenation - Other interventions are aimed at preventing complications of immobility; These may include the use of anticoagulant agents & thigh-high elastic compression stockings or sequential compression boots to prevent thrombosis & PE - Plasmapheresis & IVIG are used to affect directly the peripheral nerve myelin antibody lvl; Both therapies decrease circulating antibody lvls & reduce the amount of time pt is immobilized & dependent on mechanical ventilation--Studies indicate that IVIG & plasmapheresis are equally effective in treating GBS; however, IVIG is a/w fewer side effects - The CV risks posed by autonomic dysfunction require continuous ECG monitoring; Tachycardia & HTN are treated w/ short-acting meds such as alpha-adrenergic blocking agents; The use of short-acting agents is important, b/c autonomic dysfunction is very labile; Hypotension is managed by increasing the amount of IV fluid administered

Alzheimer's Disease: Medical & Nursing Management (Providing for Socialization & Intimacy Needs)

- B/c socialization w/ friends can be comforting, visits, letters, & phone calls are encouraged; Visits should be brief & nonstressful; limiting visitors to1 or 2 at a time helps reduce overstimulation - Recreation is important, & people w/ AD are encouraged to enjoy simple activities; Realistic goals for activities that provide satisfaction are appropriate; Hobbies & activities like walking, exercising, & socializing can improve quality of life - The nonjudgmental friendliness of a pet may provide stimulation, comfort, & contentment; Care of plants or of a pet can also be satisfying & an outlet for energy - AD doesn't eliminate the need for intimacy; Pts & their spouses may continue to enjoy sexual activity; Spouses should be encouraged to talk about any sexual concerns, & sexual counseling may be necessary; Simple expressions of love, like touching & holding, are often meaningful

Multiple Sclerosis: Courses of MS (Figure 46-3)

- B/w 85-90% of pts w/ MS have a replapsing remitting (RR) course; W/ each relapse, recovery is usually complete; however, residual deficits may occur & accumulate over time, contributing to functional decline-- Approx 40% w/ the RR course progress to secondary progressive course, in which disease progression occurs w/ or w/o relapses - About 10-15% of pts have primary progressive course, in which disabling sx's steadily increase w/ rare plateaus & temporary improvement--results in quadriparesis, cognitive dysfunction, visual loss, & brainstem syndromes - Least common presentation is the progressive relapsing form, which occurs in approx 5% of pts & is characterized by relapses w/ continuous disabling progression b/w exacerbations

Bell's Palsy

- Bell's palsy (facial paralysis): caused by unilateral inflammation of the 7th cranial nerve, which results in weakness & paralysis of the facial muscles on the ipsilateral (same side) of the affected facial nerve - Although the cause is unknown, theories about causes include vascular ischemia, viral disease (herpes simplex, herpes zoster), autoimmune disease, or a combo of all of these factors - Bell's palsy may be a type of pressure paralysis; The inflamed, edematous nerve becomes compressed to the point of damage, or its blood supply is occluded, producing ischemic necrosis of the nerve

Bell's Palsy: Medical & Nursing Management

- Corticosteroid therapy (prednisone) may be prescribed to reduce inflammation & edema; this reduces vascular compression & permits restoration of blood circulation to the nerve; Early admin of corticosteroids appears to diminish the severity of the disease, relieve the pain, & prevent or minimize denervation - Facial pain is controlled w/ analgesic agents; Heat may be applied to the involved side of the face to promote comfort & blood flow through the muscles; Electrical stimulation may be applied to the face to prevent muscle atrophy - While the paralysis lasts, nursing care involves protection of the eye from injury; Frequently, the eye doesn't close completely & the blink reflex is diminished, so the eye is vulnerable to injury from dust & foreign particles; Corneal irritation & ulceration may occur; Distortion of the lower lid alters the proper drainage of tears - To prevent injury, the eye should be covered w/ a protective shield at night; The eye patch may abrade the cornea, however, b/c there is some difficulty in keeping the partially paralyzed eyelids closed - Eye ointment may be applied at bedtime to promote adherence of the eyelids to prevent injury during sleep - Pt can be taught to close the paralyzed eyelid manually before going to sleep; Wrap-around sunglasses or goggles may be worn during the day to decrease normal evaporation from the eye

Parkinson's Disease: Medical & Nursing Management (Deep Brain Stimulation)

- Deep brain stimulation is the delivery of high-frequency electrical stimulation to a select target in the brain - An electrode is placed in the thalamus & connected to a pulse generator that is implanted in a subcutaneous subclavicular or abdominal pouch; The battery-powered pulse generator sends high-frequency electrical impulses through a wire placed under the skin to a lead anchored to the skull--The electrode blocks nerve pathways in the brain that cause tremors - Deep brain stimulation usually results in pts being at their best for longer periods of the day than they were w/ meds alone; Most pts are able to reduce their intake of med, w/ a lower prevalence of side effects

Nursing Care During & After a Seizure (Box 46-2)

- During a Seizure: (1) Provide privacy & protect pt from curious onlookers (pt who has an aura [warning of an impending seizure] may have time to seek a safe, private place) (2) Ease pt to the floor, if possible (3) Protect the head w/ a pad to prevent injury (from striking a hard surface) (4) Loosen constrictive clothing, remove eyeglasses (5) Push aside any furniture that may injure pt during the seizure (6) If pt is in bed, remove pillows & raise side rails (7) If an aura precedes the seizure, insert an oral airway to reduce possibility of the pt's biting the tongue or cheek (8) Do NOT attempt to pry open jaws that are clenched in a spasm or to insert anything; Broken teeth & injury to the lips & tongue may result from such an action (9) NO attempt should be made to restrain pt during the seizure, b/c muscular contractions are strong & restraint can produce injury (10) If possible, place pt on 1 side w/ head flexed forward, which allows the tongue to fall forward & facilitates drainage of saliva & mucus; If suction is available, use it if necessary to clear secretions - After the Seizure: (1) Keep pt on 1 side to prevent aspiration;Make sure airway is patent (2) There is usually a period of confusion after a grand map seizure (3) A short apneic period may occur during or immediately after a generalized seizure (4) Pt, on awakening, should be reoriented to the environment (5) If pt becomes agitated after a seizure (postictal), use calm persuasion & gentle restraint

Encephalitits

- Encephalitis: acute inflammatory process of the brain tissue secondary to viruses, bacteria, fungi, or parasites (Herpes simplex is most common cause--2 types: HSV-1 & HSV-2) - Acyclovir (Zovirax), an antiviral agent, is the med of choice in the tx of HSV - It is shown that early admin of acyclovir improves prognosis a/w HSV-1 encephalitis & reduces a mortality rate of 70% to 28% if tx is initiated before the onset of coma - To prevent relapse, tx should continue for up to 3 wks; Slow IV admin over at least 1 hr, along w/ adequate hydration, may prevent crystallization of the med in the renal tubules, which would be reflected by a rising serum creatinine & BUN - Assessment of neurologic function is key to monitoring the progression of disease - Comfort measures to reduce HA include dimming the lights, limiting noise, & administering analgesic agents; Opioid analgesic meds may mask neurologic sx's; therefore, they are used cautiously - Focal seizures & altered LOC require care directed at injury prevention & safety - Nursing care addressing pt & family anxieties is ongoing throughout the illness - Monitoring of blood chemistry test results & hourly urinary output will alert nurse to the presence of renal complications r/t acyclovir therapy

Parkinson's Disease: Medical & Nursing Management (Enhancing Self-Care Activities)

- Environmental modifications are necessary to compensate for functional disabilities; Pts may have severe mobility problems that make normal activities impossible - Adaptive or assistive devices may be useful; A hospital bed at home w/ bedside rails, an overbed frame w/ a trapeze, or a rope tied to the foot of the bed can provide assistance in pulling up w/o help - An OT can evaluate pt's needs in the home, make recommendations regarding adaptive devices, & teach pt & caregiver how to improvise

Seizure Disorders: Epilepsy (Box 46-1)

- Epilepsy: a group of syndromes characterized by unprovoked, recurring seizures; classified by specific patterns of clinical features, including age at onset, family hx, & seizure type - Types of epilepsies are differentiated by how the seizure activity manifests, usually detected in scalp EEG recordings - The most common syndromes are those w/ generalized seizures, which involve the brain diffusely, & those w/ partial-onset seizures, which are limited to 1 side of the cerebral hemisphere - Epilepsy can be idiopathic (formerly termed primary), in which no cause is identified, or symptomatic (formerly termed secondary), when the cause is known & the epilepsy is a sx of another underlying condition, - Although some evidence suggests that susceptibility to some types of epilepsy may be inherited, the cause of seizures in many people is unknown; Epilepsy can follow birth trauma, asphyxia neonatorum, head injuries, some infectious diseases, toxicity, circulatory problems, fever, metabolic & nutritional disorders, & drug or alcohol intoxication; It is also a/w brain tumors, abscesses, & congenital malformations-- Most cases of epilepsy are idiopathic - Epilepsy is not a/w intellectual lvl; Epilepsy is not synonymous w/ mental retardation or illness; However, many people who have developmental disabilities b/c of serious neurologic damage also have epilepsy ***Not all seizures imply epilepsy; Although seizures are the cardinal sx of epilepsy, seizures also occur as a manifestation of an underlying treatable problem, like hyponatremia or high fever; Once the cause is identified & treated, the seizures cease--Epilepsy is a chronic disease, & refers to recurrent, unpredictable, & unprovoked seizures

Nursing Process: The Patient with Epilepsy & Seizures (Nursing Interventions)-- Reducing Fear of Seizures

- Fear that a seizure may occur unexpectedly can be reduced by pt's adherence to prescribed tx regimen; Cooperation of pt & family & their trust in the prescribed regimen are essential for control of seizures - Nurse emphasizes that the prescribed antiseizure med must be taken on a continuing basis & that drug dependence or addiction doesn't occur - Periodic monitoring is necessary to ensure the adequacy of the tx regimen, to prevent side effects, & to monitor for drug resistance - In an effort to control seizures, factors that may precipitate them are identified, like emotional disturbances, new environmental stressors, onset of menstruation in female pts, hypoglycemia, or fever - Pt is encouraged to follow a regular & moderate routine in lifestyle, diet (avoiding excessive stimulants), exercise, & rest (sleep deprivation may lower the seizure threshold); Moderate activity is therapeutic, but excessive exercise should be avoided - An additional dietary intervention, referred to as the ketogenic diet, has been suggested for control of seizures in some pts; however, research on this high-fat & -protein, low-carb diet only demonstrates effectiveness in children & further studies are needed to assess its efficacy in adults-- b/c of the high fat component of this diet & limited replacement of essential nutrients, additional prohibitive health complications in older pts should be considered - Photic stimulation (bright flickering lights, TV viewing) may precipitate seizures; wearing dark glasses or covering 1 eye may be preventive; Tension states (anxiety, frustration) induce seizures in some pts; Classes in stress management may be of value; B/c seizures are known to occur w/ alcohol intake, alcoholic beverages should be avoided

Guillain-Barre Syndrome (GBS)

- GBS: an autoimmune attack on the peripheral nerve myelin; the result is acute, rapid, segmental demyelination of peripheral nerved & some cranial nerves, producing ascending weakness w/ dyskinesia (inability to execute voluntary movements), hyporeflexia, & paresthesias (numbness) - An antecedent event (most often a viral infection) precipitates clinical presentation

Multiple Sclerosis: Nursing Management (Enhancing Bladder & Bowel Control)

- Generally, bladder sx's fall into the following categories: (1) inability to store urine (2) inability to empty bladder; & (3) a mixture of both types - The sensation of the need to void must be heeded immediately, so the bedpan or urinal should be readily available - A voiding time schedule is set up (every 1.5 - 2 hrs initially, w/ gradual lengthening of the interval); Pt is instructed to drink a measured amount of fluid every 2 hrs & then attempt to void 30 mins after drinking - Use of a timer or wristwatch w/ an alarm may be helpful for pt who doesn't have enough sensation to signal the need to empty the bladder; Nurse encourages pt to take the prescribed meds to treat bladder spasticity, this allows greater independence - Intermittent self-catheterization has been successful in maintaining bladder control in pts w/ MS - If a female pt has permanent urinary incontinence, urinary diversion procedures may be considered; The male pt may wear a condom appliance for urine collection - Bowel problems include constipation, fecal impaction, & incontinence; Adequate fluids, dietary fiber, & a bowel-training program are frequently effective in solving these problems

Medical & Nursing Management (Box 46-2)

- Goals of tx are to stop the seizures as quickly as possible, to ensure adequate cerebral oxygenation, & to maintain pt in a seizure-free state - In the case of prolonged seizures, as in status epilepticus, nurse recalls the standard ABCs (airway, breathing & circulation) of emergency management; Mortality rates of up to 30% are noted if the seizure lasts over 1 hr - An airway & adequate oxygenation are established; Pt is gently positioned on the side to avoid aspiration, & an oral airway may be inserted if pt's teeth are not clenched; Note that the airway is NEVER forced; O2 is administered as ordered via N/C, or, intubation may be required, & O2 is administered via the artificial airway & monitored by pulse ox; Suctioning of the airway may also be required - An IV line is established & IV diazepam (Valium), lorazepam (Ativan), or fosphenytoin (Cerebyx) is given slowly in an attempt to halt seizures immediately; Other meds (phenytoin, phenobarbital) are given later to maintain a seizure-free state - In general, a single drug is used to control the seizures, called monotherapy, the selected drug is determined by the type of seizure, & the dose is increased until sx's resolve, maximal dose is required, or signs of drug toxicity emerge, at which time alternative therapeutic agents are considered, & pt may be tapered off the first drug; The IV line is closely monitored b/c it may become dislodged during seizures - Blood samples are obtained to monitor serum electrolytes, glucose, blood cell count, & toxicology/drug screen, & lvls of drugs may be monitored if pt has been treated w/ the med; If the serum concentration of the antiseizure med is below therapeutic lvls, it suggests that pt was not taking the ,med, the dosage was too low, or factors such as pharmacokinetics of the med may be involved - EEG monitoring may be useful in determining the nature of the seizure activity; Vitals & neurologic signs are monitored on a continuing basis - An IV infusion of dextrose is given if the seizure is caused by hypoglycemia; If initial tx is unsuccessful, general anesthesia w/ a short-acting barbiturate may be used - Cardiac involvement or respiratory depression may be life-threatening; The potential for postictal cerebral edema also exists; This varies in clinical presentation & may include deterioration in neurological signs, like drowsiness to coma, nausea, vomiting, sluggish pupillary response, cardiac arrhythmias, & altered respiratory patterns

Meningitis: Clinical Manifestations (Figure 46-1)

- HA & fever are frequently the initial sx's (HA is usually either throbbing or steady & very severe; Fever tends to remain high throughout the course of the illness) - Altered LOC is frequently seen; but 1/3 of pts present w/ normal mentation - Nuchal Rigidity (stiff neck): early sign; any attempts at flexion of the head are difficult b/c of spasms in the muscles of the neck; W/ pt in supine, the head is gently flexed forward & assessed for rigidity - Positive Kernig's Sign: when pt is lying supine w/ hip flexed to 90-degree angle, resistance to passive extension of the knee is a positive Kernig's sign - Positive Brudzinski's Sign: when pt's neck is flexed (after ruling out cervical trauma or injury), flexion of the knees & hips is produced; when lower extremity of 1 side is passively flexed, a similar movement is seen in the opposite extremity - Photophobia (extreme sensitivity to light); common finding although cause is unclear - A rash can be a striking feature of N. meningitides infection; Skin lesions develop, ranging from a petechial rash w/ purpuric lesions to large areas of ecchymosis - Disorientation & memory impairment are common early in the course of the illness; The changes depend on the severity of the infection, as well as the individual response to the physiologic processes; As the illness progresses, lethargy, unresponsiveness, & coma may develop - Seizures occur in adults w/ bacterial meningitis within the 1st week & are the result of areas of irritability in the brain - ICP increases secondary to the accumulation of purulent exudate & cerebral edema; The initial signs of increased ICP include decreased LOC & focal motor deficits; Vomiting is a frequent finding a/w a rising ICP; If ICP is not controlled, the uncus of the temporal lobe may herniate through the tentorium, causing pressure on the brainstem; Brainstem herniation is a life-threatening event that causes cranial nerve dysfunction & depresses the centers of vital functions - An acute fulminant infection occurs in about 10% of pts w/ meningococcal meningitis, producing signs of overwhelming septicemia: an abrupt onset of high fever, extensive purpuric lesions (over face & extremities), shock, & signs of disseminated intravascular coagulopathy (DIC) - If the clinical presentation suggests meningitis, diagnostic testing is conducted to identify the causative organism; Bacterial culture & Gram staining of CSF & blood are key diagnostic tests

Multiple Sclerosis: Nursing Management (Preventing Injury)

- If motor dysfunction causes coordination problems & clumsiness, or if ataxia is apparent, pt is at risk for falling--To overcome this, pt is taught to walk w/ feet apart to widen the base of support & to increase walking stability - if loss of position sense occurs, pt is taught to watch feet while walking - Gait training may require assistive devices & instruction about their use--If gait remains inefficient, a wheelchair/ motorized scooter may be the soln - Occupational therapist is a valuable resource person in suggesting & securing aids to promote independence; Pt is trained in transfers & ADLs - Bc sensory loss may also occur, pressure ulcers are a continuing threat to skin integrity

Multiple Sclerosis: Nursing Management (Enhancing Communication & Managing Swallowing Difficulties)

- If the cranial nerves that control mechanisms of speech & swallowing are affected, dysarthrias (defects of articulation) marked by slurring, low volume of speech, & difficulties in phonation may occur; Dysphagia (difficulty swallowing) may also occur - A speech therapist evaluates speech & swallowing & instructs py, family, & health team members about strategies to compensate for speech & swallowing problems--Nurse reinforces this instruction & encourages pt & family to adhere to the plan - Impaired swallowing increases pt's risk for aspiration; therefore, strategies are needed to reduce that risk; Such strategies include having suction apparatus available, careful feeding, & proper positioning for eating

Nursing Process: The Patient with Epilepsy & Seizures (Nursing Interventions)--Preventing Injury

- If the type of seizure pt is having places him/ her at risk for injury, pt should be lowered gently to the floor (if not in bed), & any potentially harmful items nearby (e.g. furniture, eyeglasses) should be removed - Pt should NEVER be restrained or forced into a position, nor should anyone attempt to insert anything into pt's mouth once a seizure has begun (protecting the airway is a priority) - Pts for whom seizure precautions are instituted should have pads applied to the side rails when in bed

Alzheimer's Disease: Clinical Manifestations & Assessment (Table 46-3)

- In early stages of AD, forgetfulness & subtle memory loss occur; Pts may experience small difficulties in work or social activities but have adequate cognitive function to hide the loss & function independently; Depression may occur - W/ further progression of AD, the deficits can no longer be concealed; Forgetfulness is manifested in many daily actions; pts may lose their ability to recognize familiar faces, places, & objects, & they may become lost in a familiar environment; They may repeat the same stories b/c they forget that they have already told them--Trying to reason w/ people w/ AD & using reality orientation only increases their anxiety w/o increasing function -Conversation becomes difficult, & word-finding difficulties occur; The ability to formulate concepts & think abstractly disappear - Pts are often unable to recognize the consequences of their actions & will therefore exhibit impulsive behavior; Pts have difficulty w/ everyday activities, like operating simple appliances & handling money - Personality changes are also usually evident; Pts may become depressed, suspicious, paranoid, hostile, & even combative - Progression of the disease intensifies the sx's: speaking skills deteriorate to nonsense syllables, agitation & physical activity increase, & pts may wander at night; Eventually, assistance is needed for most ADLs, including eating & toileting, b/c dysphagia & incontinence develop - The late stages, in which pts are usually immobile & require total care, may last months or yrs - Occasionally, pts may recognize family members or caregivers; Death occurs as a result of complications like pneumonia, malnutrition, or dehydration. - A definitive dx of AD is made based on meeting the clinical criteria & histological evidence based on exam of brain tissue obtained from biopsy or autopsy; The most important goal is to rule out other causes of dementia or reversible causes of confusion, like other types of dementia, depression, delirium, alcohol/ drug abuse, or inappropriate drug dosage or drug toxicity - The health hx—including medical hx, family hx, social & cultural hx, & med hx—& the physical exam, including functional & mental health status, are essential to the dx of probable AD - Diagnostic tests, including CBC, chemistry profile, & vitamin B12 & thyroid hormone lvls, as well as screening w/ EEG, CT, MRI, & examination of the CSF may all refute or support a dx of probable AD - Depression can closely mimic early-stage AD & coexists in many pts; A depression scale is helpful in screening for underlying depression - Tests of cognitive function like the Mini-Mental Status Exam & the clock-drawing test are useful for screening; CT & MRI scans of the brain are useful for excluding hematoma, brain tumor, stroke, normal-pressure hydrocephalus, & atrophy but are not reliable in making a definitive dx of AD - Infections, physiologic disturbances like hypothyroidism, PD, & vitamin B12 deficiency can cause cognitive impairment that may be misdiagnosed as AD - Biochemical abnormalities can be excluded through exam of the blood & CSF, but the findings are not sufficiently specific to make the dx - AD is a diagnosis of exclusion, & a diagnosis of probable AD is made when the medical hx, physical exam, & lab tests have excluded all known causes of other dementias

Myasthenia Gravis: Clinical Manifestation & Assessment

- Initial manifestation of MG usually involves the ocular muscles; Diplopia & ptosis (drooping of the eyelids) are common - Majority of pts also experience weakness of the muscles of the face & throat (bulbar sx's) & generalized weakness; Weakness of the facial muscles results in a bland facial expression; Laryngeal involvement produces dysphonia (voice impairment) & increases pt's risk for chocking & aspiration - Generalized weakness affects all the extremities & the intercostal muscles, resulting in decreasing vital capacity & respiratory failure - MG is purely a motor disorder w/ no effect on sensation or coordination - An acetylcholinesterase test is used to dx MG; The acetylcholinesterase inhibitor stops the breakdown of acetylcholine, thereby increasing availability at the neuromuscular junction; The drug used is edrophonium chloride (Tensilon), b/c it has a rapid onset of 30 secs & a short duration of 5 mins; Immediate improvement in muscle strength after admin of this agent represents a positive test & usually confirms dx - The presence of acetylcholine receptor antibodies is identified in serum - Repetitive nerve stimulation demonstrates a decrease in successive action potentials; The thymus gland may be enlarged in MG, & a CT of the mediastinum is performed to detect thymoma or hyperplasia of the thymus

Clinical Manifestations & Assessment

- Initial pattern of the seizures indicates the region of the brain in which the seizure originates - Simple Partial Seizures: only a finger or had ay shake, or the mouth may jerk uncontrollably; Person may talk unintelligibly, may be dizzy, & may experience unusual or unpleasant sights, sounds, odors, or tastes, but w/o LOC - Complex Partial Seizures: person either remains motionless or moves automatically but inappropriately for time & place, or he/she may experience excessive emotions of fear, anger, elation, or irritability--the person doesn't remember the episode when it is over - Generalized Seizures: previously called grand mal seizures; involve both hemispheres of the brain, causing both sides of the body to react; Intense rigidity of the entire body may occur, followed by alternating muscle relaxation & contraction (generalized tonic-clonic contraction); The simultaneous contractions of the diaphragm & chest muscles may produce a characteristic epileptic cry; The tongue is often chewed, & pt is incontinent of urine & feces; After 1- 2 mins, the convulsive movements begin to subside; the pt relaxes & lies in deep coma, breathing noisily; The respirations at this point are chiefly abdominal; In the postictal (after the seizure) state, pt is often confused & hard to arouse & may sleep for hrs; Many pts report HA, sore muscles, extremity weakness, fatigue, & depression - A medical hx is taken, including previous seizure hx, alcohol & drug use, medication use, allergy status, & family hx; Pt is also questioned about illnesses or head injuries that may have affected the brain - Women should be questioned about their last menstrual period (increased in seizure frequency is noted during menses) & pregnancy status (fetal anomaly is 2X higher in women taking antiepileptic meds) - Pt is asked about common triggers a/w seizures which can be olfactory (particular odors), visual (flashing lights), or auditory (certain types of music) in nature, or r/t fatigue, sleep deprivation, hypoglycemia, emotional stress, electrical shock, febrile illness, alcohol consumption, certain drugs, drinking too much water, constipation, & hyperventilation - In addition to physical & neurologic evals, diagnostic exams include biochemical, hematologic, & serologic studies; Imaging studies like MRI, magnetic resonance spectroscopy (MRS), & PET may be used to detect structural lesions like focal abnormalities, cerebrovascular abnormalities, & cerebral degenerative changes; SPECT is an additional tool that is sometimes used in the diagnostic workup; It is useful for identifying the epileptogenic zone so that the area in the brain giving rise to seizures can be removed surgically - The EEG furnishes diagnostic evidence for a substantial proportion of pts w/ epilepsy & assists in classifying the type of seizure; Abnormalities in the EEG usually continue b/w seizures or, if not apparent, may be elicited by hyperventilation or during sleep - Microelectrodes (depth electrodes) can be inserted deep in the brain to probe the action of single brain cells; Some people w/ clinical seizures have normal EEGs, whereas others who have never had seizures have abnormal EEGs - Telemetry & computerized equipment are used to monitor electrical brain activity while the pt pursues his or her normal activities & to store the readings on computer tapes for analysis; Video recording of seizures taken simultaneously w/ EEG telemetry is useful in determining the type of seizure as well as its duration & magnitude; This type of intensive monitoring is changing the tx of severe epilepsy

Parkinson's Disease: Medical & Nursing Management (Antiparkinsonian Medications) (Table 46-2)

- Levodopa is the most effective agent & the mainstay of tx--this med is converted to dopamine in the balsa ganglia, producing sx relief - Beneficial effects of this med are most pronounced in the first few yrs of tx, benefits begin to wane & adverse effects become more severe over time - Within 5-10 yrs, most pts develop a response to the med characterized by dyskinesia (abnormal involuntary movement) - Pt may experience an on-off syndrome, in which udder periods of near-immobility ("off-effect") are followed by a sudden return of effectiveness of the med ("on effect")

Myasthenia Gravis (MG) (Figure 46-4)

- MG: an autoimmune disorder affecting the neuromuscular junction; characterized by fatigability & degrees of muscle weakness of the voluntary muscles; occurs in men & women at older ages, but before 40, it is 3X more common in women; Most common age of onset is 2nd & 3rd decades in females & 7th & 8th decades in males - Normally, a chemical impulse precipitates the release of acetylcholine from vesicles on the nerve terminal at the neuromuscular junction; The acetylcholine attaches to receptor sites on the motor endplate & stimulates muscle contraction; Continuous binding of acetylcholine to the receptor site is required for muscular contraction to be sustained - In myasthenia gravis, there is a reduction in the # of acetylcholine receptor sites b/c antibodies directed at the acetylcholine receptor sites impair transmission of impulses across the neuromuscular junction-- Therefore, fewer receptors are available for stimulation, resulting in voluntary muscle weakness that escalates w/ continued activity - Hyperplasia & tumors of the thymus (located behind the sternum) are frequently found in MG pts

Multiple Sclerosis: Nursing Management (Improving Home Management)

- MS can affect every facet of daily living; Certain abilities are often impossible to regain after they are lost; Physical function may vary from day to day - Modifications that allow independence in home management should be implemented (e.g. assistive eating devices, raised toilet seat, bathing aids, telephone modifications, long-handled comb, tongs, modified clothing) - Exposure to heat increases fatigue & muscle weakness, so air conditioning is recommended in at least 1 room; Exposure to extreme cold may increase spasticity

Multiple Sclerosis (MS) (Figure 46-2)

- MS: leading cause of non traumatic disability in young adults; it is an immune-mediated, progressive demylinating disease of the CNS - Demyelination refers to the destruction of myelin (the fatty & proteinaceous material that surrounds certain nerve fibers in the brain & spinal cord); Results in impaired transmission of nerve impulses - May occur at any age, but typically in young adults b/w 20-40; affects women more then men& rarely affects those over 60 -Etiology of MS is unknown, & may result from complex interactions b/w environmental factors & genetically susceptible individuals that trigger an abnormal immune response that damages the myelin sheath, oligodendrocytes, axons, & neurons - Evidence for genetic predisposition is seen in an increased risk for Caucasian of northern European ancestry & a decreased risk in others

Medical & Nursing Management: Pharmacologic Therapy (Table 46-1)

- Many meds are available to control seizures, but nurse stresses that the tx is NOT curative; The objective is to achieve seizure control w/ minimal side effects - Meds are selected on basis of pt's type of seizure & the effectiveness & safety of the meds - Tx usually starts w/ a single med; Starting dose & the rate at which the dosage is increased depend on the occurrence of side effects; The med lvls in the blood are monitored b/c the rate of drug absorption varies among pts - Changing to another med may be necessary if seizure control is not achieved or if toxicity makes it impossible to increase the dosage - Med may need to be adjusted b/c of concurrent illness, weight changes, or increases in stress - Sudden withdrawal of these meds can cause seizures to occur w/ greater frequency or can precipitate the development of status epileptics - Side effects of antiseizure agents may be divided into 3 groups: (1) idiosyncratic or allergic disorders, which manifest primarily as skin reactions; (2) acute toxicity, which may occur when the med is initially prescribed; & (3) chronic toxicity, which occurs late in the course of therapy - The manifestations of drug toxicity are variable, & any organ system may be involved - Gingival hyperplasia (swollen & tender gums) can be a/w LT use of phenytoin (Dilantin)--Periodic physical & dental exams & lab tests are performed for pts receiving meds that are known to have hematopoietic, genitourinary, or hepatic effects

Alzheimer's Disease: Medical & Nursing Management (Promoting Balanced Activity & Rest)

- Many pts w/ AD exhibit sleep disturbances, wandering, & behaviors that may be considered inappropriate--These behaviors are most likely to occur when there are unmet underlying physical or psychological needs - Caregivers must identify the needs of pts who are exhibiting these behaviors b/c further health decline may occur if the source of the problem is not corrected - Adequate sleep & physical exercise are essential; If sleep is interrupted or pt can't fall asleep, music, warm milk, or a back rub may help pt to relax - During the day, pts should be encouraged to participate in exercise b/c a regular pattern of activity & rest enhances nighttime sleep; Long periods of daytime sleeping are discouraged

Alzheimer's Disease: Medical & Nursing Management (Promoting Adequate Nutrition)

- Mealtime can be a pleasant social occasion or a time of upset & distress, & it should be kept simple & calm, w/o confrontations - Pts prefer familiar foods that look appetizing & taste good; To avoid any "playing" w/ food, one dish is offered at a time; Food is cut into small pieces to prevent choking; Liquids may be easier to swallow if they are converted to gelatin; Hot food & beverages are served warm, & temp of the foods should be checked to prevent burns - When lack of coordination interferes w/ self-feeding, adaptive equipment is helpful; Some pts may do well eating w/ a spoon or w/ their fingers; If this is the case, an apron or a smock, rather than a bib, is used to protect clothing - As deficits progress, it may be necessary to feed pt - Forgetfulness, disinterest, dental problems, lack of coordination, overstimulation, & choking may all serve as barriers to good nutrition & hydration

Meningitis

- Meningitis: an inflammation of the protective membrane covering the brain & spinal cord (meninges); classified as septic or aseptic - Septic meningitis is caused by bacteria (common: Steptococcus pneumonia, Neisseria meningitidis (meningococcus); For pts over 50: Listeria monocytogenes, aerobic gram-negative bacilli; Haemophilus influenza less common now due to vaccine - N. meningitidis most likely occur in dense community groups, like college campuses & military installations - Peak incidence is in winter & early spring - Factors that increase risk for bacterial meningitis include tobacco use & viral upper respiratory infection b/c they increase amount f droplet production; Otitis media & mastoiditis increase incidence b/c the bacteria cross the epithelial membrane & enter subarachnoid space; Preexisting diabetes & alcohol abuse, asplenia (no spleen), & immune sys deficiencies (chemo, AIDS, ect) are also risk factors - Aseptic meningitis is viral or secondary to lymphoma, leukemia, HIV, or chemical irritants

Parkinson's Disease: Clinical Manifestations & Assessment (Tremor)

- Most common reason why individuals seek medical evaluation is the presence of a resting tremor - Resting tremor characteristically disappears w/ purposeful movement but is evident when the extremities are motionless - The tremor may manifest as a rhythmic, slow-turning motion (pronation-supination) of the forearm & the hand & a motion of the thumb against the fingers as if rolling a pill b/w the fingers - Tremor is present while pt is at rest; it increases when pt is walking, concentrating, or feeling anxious

Multiple Sclerosis: Nursing Management

- NO CURE exists for MS - Goals of tx are to treat acute exacerbations, delay progression of the disease, & manage chronic sx's - Sx's requiring intervention include spasticity, fatigue, bladder dysfunction, & ataxia

Nursing Process: The Patient with Epilepsy & Seizures (Assessment)

- Nurse elicits info about pt's seizure hx; Pt is asked about the factors or events that may precipitate the seizures; Alcohol intake is documented. -Nurse determines whether pt has an aura before an epileptic seizure, which may indicate the origin of the seizure (e.g. seeing a flashing light may indicate that the seizure originated in the occipital lobe) - Observation & assessment during & after a seizure assist in identifying the type of seizure & its management - The effects of epilepsy on the patient pt's lifestyle are assessed (What limitations are imposed by the seizure disorder?,Does pt have a recreational program?, Social contacts?, Is pt working, & is it a positive or stressful experience?, What coping mechanisms are used?)

Medical & Nursing Management Cont'd

- Nurse initiates ongoing assessment & monitoring of respiratory & cardiac function b/c of the risk for delayed depression of respiration & BP secondary to administration of antiseizure meds & sedatives to halt the seizures - Nursing assessment also includes monitoring & documenting the seizure activity & pt's responsiveness - A person who has received LT antiseizure therapy has a significant risk for fractures resulting from bone disease (osteoporosis, osteomalacia, & hyperparathyroidism), a side effect of therapy; Therefore, during seizures, pt is protected from injury w/ the use of seizure precautions, which include padding side rails of the bed, maintaining bed in the low position, ensuring side rails are up & that suction, an oral airway, & O2 are available at the bedside, & pt is monitored closely - NO effort should be made to restrain movements; Pt having seizures can inadvertently injure nearby people, so nurses should protect themselves **Phenytoin (Dilantin), if ordered intravenously, must be given slowly b/c of its effect on the myocardium & the potential for arrhythmia development; In addition, it is irritating to the vein; thus, nurse observes for development of phlebitis( rate of admin is no faster than 50 mg/min in normal saline soln, since the drug precipitates in D5W); If the preexisting soln contained dextrose, nurse flushes IV line w/ normal saline before administering the med; Many antiepileptic drugs are highly bound to plasma protein, & nurse is aware that only the unbound, or "free," serum concentration is available for use by the body; Pts on high-protein tube feedings may require higher dosages to maintain therapeutic blood lvls, while those w/ hypoalbuminemia b/c of malnutrition, burns, or liver or renal disease may require alternative dosing to prevent phenytoin toxicity (Therapeutic range for phenytoin is 10 to 20 mg/L)

Nursing Process: The Patient with Epilepsy & Seizures (Nursing Interventions)-- Providing Patient & Family Education

- Nurse provides education & efforts to modify the attitudes of pt & family toward the disorder - The person who experiences seizures may consider every seizure a potential source of humiliation & shame; This may result in anxiety, depression, hostility, & secrecy on the part of pt & family - Ongoing education & encouragement should be given to pts to enable them to overcome these reactions - Pt w/ epilepsy should carry an emergency medical identification card or wear a medical info bracelet - Pt & family need to be educated about meds as well as care during a seizure

Guillian- Barre Syndrome: Medical & Nursing Management (Enhancing Physical Mobility)

- Nursing interventions to enhance physical mobility & prevent the complications of immobility are key to the function & survival of these pts - The paralyzed extremities are supported in functional positions, & passive ROM exercises are performed at least twice daily - DVT & PE are threats to the paralyzed pt; Nursing interventions are aimed at preventing DVT; ROM exercises, position changes, anticoagulation, the use of thigh-high elastic compression stockings or sequential compression boots, & adequate hydration decrease risk for DVT - Padding may be placed over bony prominences, like elbows & heels, to reduce risk for pressure ulcers; The need for consistent position changes every 2 hrs can't be overemphasized - Nurse evaluates lab test results that may indicate malnutrition or dehydration, both of which increase risk for pressure ulcers; Nurse collaborates w/ provider & dietitian to develop a plan to meet pt's nutritional & hydration needs

Parkinson's Disease: Clinical Manifestations & Assessment

- PD has gradual onset & ax's progress slowly over a chronic, prolonged course--The cardinal signs are T-R-A-P (tremor, rigidity, akinesia/ bradykinesia (w/o or decreased body movement), & postural disturbances)

Parkinson's Disease: Pathophysiology

- PD is a/w decreased lvls of dopamine resulting from destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia region of the brain - Fibers or neuronal pathways project from the substantia nigra to the corpus striatum, where neurotransmitters are key to the control of complex body movements - Through the neurotransmitters acetylcholine (excitatory) & dopamine (inhibitory), striatal neurons relay messages to the higher motor centers that control & refine motor movements-- The loss of dopamine stores in this area of the brain results in more excitatory neurotransmitters than inhibitory neurotransmitters, leading to an imbalance that affects voluntary movement - Clinical symptoms don't appear until 60% of the pigmented neurons are lost & the striatal dopamine lvl is decreased by 80% - Cellular degeneration impairs the extrapyramidal tracts that control semiautomatic functions & coordinated movements; motor cells of the motor cortex & the pyramidal tracts are not affected

Parkinson's Disease (PD)

- PD: a slowly progressing neurologic movement disorder that eventually leads to disability - The degenerative or idiopathic form is the most common; there is also a secondary form w/ a known or suspected cause - Although the cause of most cases is unknown, research suggests several causative factors, including genetics, atherosclerosis, excessive accumulation of oxygen free radicals, viral infections, head trauma, chronic use of antipsychotic meds, & some environmental exposures - Parkinsonian sx's usually 1st appear in the 5th decade of life; however, cases have been dx'd as early as 30; PD affects men more frequently than women

Guillian- Barre Syndrome: Medical & Nursing Management (Providing Adequate Nutrition)

- Paralytic ileus may result from insufficient PNS activity; In this event, nurse administers IV fluids a&d parenteral nutrition as prescribed & monitors for the return of bowel sounds & bowel function - If pt can't swallow due to bulbar paralysis (immobility of muscles), a gastrostomy tube may be placed to administer nutrients; Nurse carefully assesses return of the gag reflex & bowel sounds before resuming oral nutrition

Alzheimer's Disease: Medical & Nursing Management (Promoting Independence in Self- Care Activities)

- Pathophysiologic changes in the brain make it difficult for people w/ AD to maintain physical independence - Pts should be assisted to remain functionally independent for as long as possible; One way to do this is to simplify daily activities by organizing them into short, achievable steps so that pt experiences a sense of accomplishment - Frequently, OT can suggest ways to simplify tasks or recommend adaptive equipment - Direct pt supervision is sometimes necessary, but maintaining personal dignity & autonomy is important for pts w/ AD, who should be encouraged to make choices when appropriate & to participate in self-care activities as much as possible

Guillian- Barre Syndrome: Medical & Nursing Management (Decreasing Fear & Anxiety)

- Pt & family are faced w/ a sudden, potentially life-threatening disease, & anxiety & fear are constant themes for them; The impact of disease on the family depends on the pt's role within the family; Referral to a support group may provide info & support to pt & family - The family may feel helpless in caring for pt; Mechanical ventilation & monitoring devices may frighten & intimidate them; Family members often want to participate in physical care; w/ instruction & support by the nurse, they should be allowed to do so - Pt may experience isolation, loneliness, & lack of control; Nursing interventions that increase pt's sense of control include providing info about the condition, emphasizing a positive appraisal of coping resources, & teaching relaxation exercises & distraction techniques - The positive attitude & atmosphere of the multidisciplinary team are important to promote a sense of well-being - Diversional activities are encouraged to decrease loneliness & isolation; Encouraging visitors, engaging visitors or volunteers to read to pt, listening to music or books on tape, & watching TV are ways to alleviate pt's sense of isolation

Parkinson's Disease: Medical & Nursing Management (Improving Bowel Elimination)

- Pt may have severe problems w/ constipation; Among the factors causing constipation are weakness of the muscles used in defecation, lack of exercise, inadequate fluid intake, & decreased ANS activity; Meds used for tx of the disease also inhibit normal intestinal secretions - A regular bowel routine may be established by encouraging pt to set a specific time of day to sit on the toilet w/o distractions, consciously increase fluid intake, & eat foods w/ moderate fiber content; Laxatives should be avoided - A raised toilet seat is useful, b/c pt has difficulty in moving from a standing to a sitting position

Parkinson's Disease: Medical & Nursing Management (Improving Nutrition)

- Pts may have difficulty maintaining their weight; Eating becomes a very slow process, requiring concentration due to a dry mouth from meds & difficulty chewing & swallowing--These pts are at risk for aspiration b/c of impaired swallowing & the accumulation of saliva; They may be unaware that they are aspirating; subsequently, bronchopneumonia may develop - Monitoring weight on a weekly basis indicates whether caloric intake is adequate; Supplemental feedings increase caloric intake - As the disease progresses, a NG tube or percutaneous endoscopic gastroscopy may be necessary to maintain adequate nutrition; A dietitian can be consulted regarding nutritional needs - An electric warming tray keeps food hot & allows pt to rest during the prolonged time that it may take to eat; Special utensils also assist at mealtime--A plate that is stabilized, a nonspill cup, & eating utensils w/ built-up handles are useful self-help devices (The OT can assist in identifying appropriate adaptive devices)

Alzheimer's Disease: Medical & Nursing Management (Reducing Anxiety & Agitation)

- Pts need constant emotional support that reinforces a positive self-image--When losses of skills occur, goals are adjusted to fit the pt's declining ability - Environment should be kept familiar & noise-free; Excitement & confusion can be upsetting & may precipitate a combative, agitated state known as catastrophic reaction (overreaction to excessive stimulation); Pt may respond by screaming, crying, or becoming abusive (physically or verbally)--This may belt's only way of expressing an inability to cope w/ environment -When this occurs, it is important to remain calm & unhurried; Forcing pt to proceed w/ the activity only increases agitation; It is better to postpone activity until later - Frequently, pt quickly forgets what triggered the reaction; Measures such as moving to a familiar environment, listening to music, stroking, rocking, or distraction may quiet pt; Structuring activity is also helpful - Becoming familiar w/ a particular pt's predicted responses to certain stressors helps caregivers avoid similar situations - Many older people w/ AD who have progressed to the late stages of the disease typically reside in nursing homes & are predominantly cared for by nurses' aides; Dementia education for caregivers is essential to minimize pt agitation & can be effectively taught by advanced practice nurses

Multiple Sclerosis: Nursing Management (Promoting Sexual Functioning)

- Pts w/ MS & their partners face problems that interfere w/ sexual activity, both as a direct consequence of nerve damage & also from psychological reactions to the disease - Easy fatigability, conflicts arising from dependency & depression, emotional lability & loss of self-esteem compound the problem; Erectile & ejaculatory disorders in men & orgasmic dysfunction & adductor spasms of the thigh muscles in women can make sexual intercourse difficult or impossible - Bladder & bowel incontinence & UTIs add to the difficulties - An experienced sexual counselor helps bring into focus pt's or partner's sexual resources & suggests relevant info & supportive therapy - Sharing & communicating feelings, planning for sexual activity (to minimize the effects of fatigue), & exploring alternative methods of sexual expression may open up a wide range of sexual enjoyment & experiences

Myasthenia Gravis: Pharmacologic Therapy

- Pyridostigmine bromide (Mestinon), an anticholinesterase med, is the 1st line of therapy; It provides symptomatic relief by inhibiting the breakdown of acetylcholine & increasing the relative concentration of available acetylcholine at the neuromuscular junction-- The dosage is gradually increased to a daily maximum & is administered in divided doses (usually 4X a day); The most common adverse effects are GI discomfort, increased bronchial & oral secretions, & muscle fasciculations & cramps; Pyridostigmine tends to have fewer side effects than other anticholinesterase meds - If pyridostigmine bromide doesn't improve muscle strength & control fatigue, the next agents used are immunosuppressant agents; The goal of immunosuppressive therapy is to reduce production of the antibody; Corticosteroids suppress pt's immune response, decreasing the amount of antibody production, & this correlates w/ clinical improvement; An initial dose of prednisone is given daily; as sx's improve, the med is tapered & a maintenance alternative day dosing may be considered - Since LT steroids carry substantial risks for a variety of dose-dependent side effects (diabetes, osteoporosis, HTN), this tx is usually reserved for pts w/ ocular ax's; As the corticosteroid dosage is gradually increased, the anticholinesterase dosage is lowered - Cytotoxic meds are used to treat MG if there is inadequate response to steroids; Azathioprine (Imuran), an immunosuppressive drug, inhibits T lymphocytes & reduces acetylcholine receptor antibody lvls; Therapeutic effects may not be evident for 3- 12 months; Leukopenia & hepatotoxicity are serious adverse effects, so monthly evaluation of liver enzymes & WBC count is necessary - A # of meds are contraindicated for pts w/ MG b/c they exacerbate the ax's; The HCP & pt should weigh risks & benefits before any new meds are prescribed, including antibiotics, CV meds, antiseizure & psychotropic meds, morphine, quinine & related agents, beta blockers, & nonprescription meds; Procaine (Novocain) should be avoided, & pt's dentist is advised of the sx of MG - Since neuromuscular blocking agents may have a very prolonged effect in MG pts, any anesthetic med should be evaluated by the PCP to ensure it is not capable of exaggerating myasthenic weakness

Multiple Sclerosis: Nursing Management (Promoting Physical Mobility)

- Relaxation & coordination exercises promote muscle efficiency; Progressive resistive exercises are used to strengthen weak muscles, b/c diminishing muscle strength is often significant in MS - Exercises: Walking improves gait, & helps w/ the problem of loss of position sense of the legs & feet; If certain muscle groups are irreversibly affected, other muscles can be trained to compensate; Instruction in the use of assistive devices may be needed to ensure safe & correct use - Minimizing Spasticity & Contractures: Muscle spasticity is common &, in its later stages, is characterized by severe adductor spasm of the hips, w/ flexor spasm of the hips & knees; W/o relief, fibrous contractures of these joints will occur; Warm packs may be beneficial, but hot baths should be avoided b/c of risk for burn injury secondary to sensory loss & increasing sx's that may occur w/ elevation of the body temp; Daily exercises for muscle stretching are prescribed to minimize joint contractors; Special attn is given to hamstrings, gastrocnemius muscles, hip adductors, biceps, & wrist & finger flexors; Muscle spasticity is common & interferes w/ normal function; A stretch-hold-relax routine is helpful for relaxing & treating muscle spasticity-- Swimming & stationary bicycling are useful, & progressive weight bearing can relieve spasticity in the legs; Pt shouldn't be hurried in any of these activities, b/c this often increases spasticity - Activity & Rest: pt is encouraged to work & exercise to a point just short of fatigue; Very strenuous physical exercise is NOT advisable, b/c it raises the body temp & may aggravate ax's; Pt is advised to take frequent short rest periods, preferably lying down; Extreme fatigue may contribute to the exacerbation of sx's - Minimizing Effects of Immobility: B/c of the decrease in physical activity that often occurs w/ MS, complications a/w immobility, including pressure ulcers, expiratory muscle weakness, & accumulation of bronchial secretions, need to be considered & steps taken to prevent them; Measures to prevent such complications include assessing & maintaining skin integrity & having pt perform coughing & deep-breathing exercises

Parkinson's Disease: Clinical Manifestations & Assessment (Rigidity)

- Resistance to passive limb movement characterizes muscle rigidity - Cogwheel rigidity is characterized by ratchet-like rhythmic contractions on passive muscle stretching - Involuntary stiffness of the passive extremity increases when another extremity is engaged in voluntary active movement - Early in disease, pt may complain of shoulder pain due to rigidity

Guillian- Barre Syndrome: Medical & Nursing Management (Maintaining Respiratory Function)

- Respiratory function can be maximized w/ incentive spirometry & chest physiotherapy; Monitoring for changes in vital capacity & negative inspiratory force are key to early intervention for neuromuscular respiratory failure - Mechanical ventilation is required if the vital capacity falls, making spontaneous breathing impossible & tissue oxygenation inadequate - Parameters for determining the appropriate time to begin mechanical ventilation include a vital capacity of <15 mL/kg -The potential need for mechanical ventilation should be discussed w/ pt & family on admission, to provide time for psychological preparation & decision-making--Intubation & mechanical ventilation will result in less anxiety if it is initiated on a nonemergency basis to a well-informed pt; Pt may require mechanical ventilation for a long period - Bulbar weakness that impairs ability to swallow & clear secretions is another factor in the development of respiratory failure in pt w/ GBS; Suctioning may be needed to maintain a clear airway - Nurse assesses BP & HR frequently to identify autonomic dysfunction, so that interventions can be initiated quickly if needed; Meds are administered for clinically significant sx's

Nursing Process: The Patient with Epilepsy & Seizures (Nursing Diagnosis)

- Risk of injury r/t seizure activity -Fear r/t the possibility of seizures - Ineffective individual coping r/t stresses imposed by epilepsy - Deficient knowledge r/t epilepsy & its control -Collaborative Problems/Potential Complications: major potential complications for pts w/ epilepsy are status epilepticus & med side effects (toxicity)

Multiple Sclerosis: Clinical Manifestations

- S/s of MS are varied & multiple, reflecting the location of the lesion (plaque) or combination of lesions - Primary sx's most commonly reported are unilateral visual loss, typically preceded or accompanied by orbital pain that increases w/ eye movement (acute optic neuritis), fatigue, depression, weakness, limb (typically legs) numbness, difficulty in coordination, loss of balance, & pain - Visual disturbances due to lesions in optic nerves or their connections may also include blurring of vision, diplopia, nystagmus (rotary oscillation of the eyes), patchy blindness (scotoma), & total blindness - Fatigue is one of the more common sx's of MS; it is typically worse in the afternoon hrs; Depression, heat, anemia, deconditioning, & meds may contribute to fatigue; The etiology of MS-related fatigue is poorly understood but research doesn't demonstrate an association b/w fatigue & disease course - Like fatigue, pain is a sx that can contribute to social isolation; Lesions on sensory pathways cause pain; Many people w/ MS need daily analgesics; In some cases, pain is managed w/ opioids, antiseizure meds, or antidepressants; Rarely, surgery may be needed to interrupt pain pathways - Additional sensory manifestations include paresthesias (abnormal skin sensations such as tingling, itching or burning), dysesthesias (unpleasant, abnormal sense of touch), & proprioception (ability to sense the position & location & orientation & movement of the body & its parts) loss - An objective sensory loss (position, vibration, shape, texture) is noted in some MS pts - Among perimenopausal women, those w/ MS are more likely to have pain r/t osteoporosis; In addition to estrogen loss, immobility & corticosteroid therapy play a role in the development of osteoporosis among women w/ MS--Recent research reveals that the duration of the disease & decrease in functional capacity are the main factors that affect bone mineral density in premenopausal MS pts ; BMD testing is recommended for this high-risk group - Spasticity (muscle hypertonicity) of the extremities (usually legs) & loss of the abdominal reflexes result from involvement of the main motor pathways (pyramidal tracts) of the spinal cord; The spasticity often occurs w/ painful spasms, which interfere w/ mobility, sleep, & ADLs - Gait abnormalities are common & are usually a result of ataxia, weakness, or spasticity - Cognitive & psychosocial problems may reflect frontal or parietal lobe involvement; Some degree of cognitive impairment (e.g. memory loss, decreased concentration) occurs in about 65% of pts, but severe cognitive changes w/ dementia are rare - Involvement of the cerebellum or basal ganglia can produce ataxia (impaired coordination of movements) & tremor - Loss of the control connections b/w the cortex & the basal ganglia may occur & cause emotional lability & euphoria - Bladder, bowel, & sexual dysfunctions are common - Secondary complications of MS include UTIs, constipation, pressure ulcers, contracture deformities, dependent pedal edema, pneumonia, reactive depression, & decreased bone density; Emotional, social, marital, economic, & vocational problems may also be a consequence of the disease - Exacerbations & remissions are characteristic of MS; During exacerbations, new sx's appear & existing ones worsen; during remissions, sx's decrease or disappear - Relapses may be a/w periods of emotional & physical stress including emotional stress; cold or humid, hot weather; hot baths; overheating; fever; fatigue; & pregnancy - There is no single test for the dx of MS; Dx is established based upon clinical exam, results from MRI & evoked potential studies (EPS), & exam of CSF - MRI studies reveal abnormalities; Electrophoresis of CSF identifies the presence of oligoclonal banding; EPS can help define the extent of the disease process & monitor changes

Seizure Disorders: Seizures

- Seizures: temporary episodes of abnormal motor, sensory, autonomic, or psychic activity that results from sudden excessive electrical discharge from cortical neurons; part or all of the brain may be involved--the term octal refers to an actual seizure of octal event

Multiple Sclerosis: Pathophysiology

- Sensitized T cells typically cross the blood-brain barrier; their function is to check the CNS for antigens & then leave - In MS, the sensitized T cells remain in the CNS & promote the infiltration of other agents that damage the immune system; The immune sys attack leads to inflammation that destroys myelin (normally insulated axon & speeds conduction of impulses along axon) & the oligodendroglial cells that produce myelin in the CNS - Demyelination interrupts the flow of nerve impulses & results in a variety of manifestations, depending on the nerves affected - Plaques appear on demyelinated axons, further interrupting the transmission of impulses - Demyelinated axons are scattered irregularly throughout the CNS; The areas most frequently affected are the optic nerves, chiasm, & tracts; the cerebrum; the brainstem & cerebellum; & the spinal cord--Eventually, the axons themselves begin to degenerate, resulting in permanent & irreversible damage

Parkinson's Disease: Medical & Nursing Management (Improving Communication)

- Speech disorders are present in most pts w/ PD; Their low-pitched, monotonous, soft speech requires that they make a conscious effort to speak slowly, w/ deliberate attn to what they are saying - Pt is reminded to face the listener, exaggerate the pronunciation of words, speak in short sentences, & take a few deep breaths before speaking - A ST may be helpful in designing speech improvement exercises & assisting family & health care personnel to develop & use a method of communication that meets pt's needs; A small electronic amplifier is helpful if pt has difficulty being heard

Seizure Disorders: Status Epilepticus

- Status epilepticus (acute prolonged seizure activity): a series of generalized seizures that occur w/o full recovery of consciousness b/w attacks - The term has been broadened to include continuous clinical or electrical seizures (on EEG) lasting at least 30 mins, even w/o impairment of consciousness. - It is considered a medical EMERGENCY, w/ a mortality rate of 20% - Status epilepticus produces cumulative effects; Vigorous muscular contractions impose a heavy metabolic demand & can interfere w/ respirations; The respiratory difficulties that occur during status epilepticus can result in hypoxia to the brain; Repeated episodes of cerebral anoxia & edema may lead to irreversible & fatal brain damage - Length of time of the uncontrolled seizures increases the systemic effects of respiratory compromise, acidemia, hypoglycemia, & hypotension - Factors that precipitate status epilepticus include withdrawal of antiseizure meds, fever, concurrent infection, & withdrawal from alcohol or drugs

Nursing Process: The Patient with Epilepsy & Seizures (Nursing Interventions)--Monitoring & Managing Potential Complications

- Status epilepticus, the major complication, was described previously - Another complication is the toxicity of meds; Pt & family are instructed about side effects & are given specific guidelines to assess & report s/s that indicate med overdose - Many antiseizure meds require careful monitoring for therapeutic lvls; Pt should plan to have serum drug lvls assessed at regular intervals. Many known drug interactions occur w/ anti seizure meds - A complete pharmacologic profile should be reviewed w/ pt to avoid interactions that either potentiate or inhibit the effectiveness of the meds

Meningitis: medical & Nursing Management

- Successful outcomes depend on early administration of antibiotics that cross the blood-brain barrier into the subarachnoid space in sufficient concentration to stop the multiplication of bacteria--Penicillin antibiotics or one of the cephalosporins may be used; Vancomycin hydrochloride alone or in combo w/ rifampin may be used if resistant strains of bacteria are identified - High doses of the appropriate antibiotic are given IV; Use of dexamethasone as an adjunct therapy in tx of acute bacterial meningitis & in pneumococcal meningitis, if given before the 1st dose of antibiotic, has been considered-- However, recent results of a meta-analysis didn't demonstrate significant reduction in death or neurological disability w/ steroid use - Dehydration & shock are treated w/ fluid volume expanders; Seizures, which may occur early in the course of the disease, are controlled w/ phenytoin (Dilantin); Increased ICP is treated as necessary - Pt w/ meningitis is critically ill; therefore, many of the nursing interventions are collaborative w/ the physician, respiratory therapist, & other members of the health care team -Pt's safety & well-being depend on sound nursing judgment; Neurologic status & vitals are continually assessed; Pulse ox & ABG values are used to quickly identify the need for respiratory support if increasing ICP compromises the brainstem; Insertion of a cuffed endotracheal tube (or tracheotomy) & mechanical ventilation may be necessary to maintain adequate tissue oxygenation - Arterial BPs are monitored to assess for incipient shock, which precedes cardiac or respiratory failure; Rapid IV fluid replacement may be prescribed, but care is taken to prevent fluid overload - Fever also increases the workload of the heart & cerebral metabolism; ICP will increase in response to increased cerebral metabolic demands--Therefore, measures are taken to reduce body temp as quickly as possible - Other important components of nursing care include the following measures: (1) Protecting pt from injury secondary to seizure activity or altered LOC (2) Monitoring daily body weight; serum electrolytes; & urine volume, specific gravity, & osmolality, esp if syndrome of inappropriate antidiuretic hormone (SIADH) is suspected (3) Preventing complications a/w immobility, like pressure ulcers & pneumonia (4) Instituting infection control precautions until 24 hrs after initiation of antibiotic therapy (oral & nasal discharge is considered infectious) - Any sudden, critical illness can be devastating to the family; B/c pt's condition is often critical & prognosis guarded, the family needs to be informed about pt's condition--Periodic family visits are essential to facilitate coping of pt & family - An important aspect of the nurse's role is to support the family & assist them in identifying others who can be supportive of them during the crisis - Additionally, it is important to consider that LT neuropsychological & otological sequelae affect up to 50% of survivors

Parkinson's Disease: Medical & Nursing Management (Supporting Coping Abilities)

- Support can be given by encouraging pt & pointing out that activities will be maintained through active participation - A combo of physiotherapy, psychotherapy, med therapy, & support group participation may help reduce the depression that often occurs - Pts often feel embarrassed, apathetic, inadequate, bored, & lonely; These feelings may be due, in part, to physical slowness & the great effort that even small tasks require; Pt is assisted & encouraged to set achievable goals - B/c PD can lead to withdrawal & depression, pts must be active participants in their therapeutic program, including social & recreational events - A planned program of activity throughout the day prevents too much daytime sleeping as well as disinterest & apathy - Every effort should be made to encourage pts to carry out the tasks involved in meeting their own daily needs & to remain independent; Doing things for pt merely to save time undermines the basic goal of improving coping abilities & promoting a positive self-concept

Medical & Nursing Management: Surgical Management

- Surgery is indicated for pts whose epilepsy results from intracranial tumors, abscesses, cysts, or vascular anomalies; Some pts have intractable seizure disorders that don't respond to meds; A focal atrophic process may occur secondary to trauma, inflammation, stroke, or anoxia - If the seizures originate in a reasonably well-circumscribed area of the brain that can be excised w/o producing significant neurologic deficits, the removal of the area generating the seizures may produce LT control & improvement - This type of neurosurgery has been aided by several advances, including microsurgical techniques, EEGs w/ depth electrodes, improved illumination & hemostasis, & the introduction of neuroleptanalgesic agents (droperidol & fentanyl)--These techniques, combined w/ use of local anesthetic agents, enable neurosurgeon to perform surgery on an alert & cooperative pt - Using special testing devices, electrocortical mapping, & the pt's responses to stimulation, the boundaries of the epileptogenic focus (the abnormal area of the brain) are determined; The abnormal epileptogenic focus is then excised - As an adjunct to med & surgery in adolescents & adults w/ partial seizures, a generator may be implanted under the clavicle; The device is connected to the vagus nerve in the cervical area, where it delivers electrical signals to the brain to control & reduce seizure activity-- An external programming sys is used by the physician to change stimulator settings; Pts can turn the stimulator on & off w/ a magnet - Resection surgery significantly reduces the incidence of seizures in pts w/ refractory epilepsy; however, more research is needed to determine the effect of surgery on quality of life, anxiety, & depression, all issues for these pts

Parkinson's Disease: Medical & Nursing Management (Enhancing Swallowing)

- Swallowing difficulties are common in PD; These can lead to problems w/ poor head control, tongue tremor, hesitancy in initiating swallowing, difficulty in shaping food into a bolus, & disturbances in pharyngeal motility - To offset these problems, pt should sit in an upright position during mealtime; A semisolid diet w/ thick liquids is easier to swallow than solids; thin liquids should be avoided - Thinking through the swallowing sequence is helpful; Pt is taught to place food on the tongue, close the lips & teeth, lift the tongue up & then back, & swallow; Pt is encouraged to chew 1st on one side of the mouth & then on the other - To control the buildup of saliva, pt is reminded to hold the head upright & make a conscious effort to swallow

Parkinson's Disease: Clinical Manifestations & Assessment (Other Manifestations) (Figure 46-6)

- The effect of PD on the basal ganglia often produces autonomic sx's that include excessive & uncontrolled sweating, paroxysmal flushing, orthostatic hypotension, gastric & urinary retention, constipation, & sexual dysfunction - Cognitive & psychiatric changes are often interrelated & may be predictive of one another; Depression is common; whether it is a reaction to the disorder or is r/t a biochemical abnormality is uncertain; Cognitive changes may appear in the form of judgment, reasoning, decision making, & memory deficits, although intellect is not usually affected - A # of psychiatric manifestations (personality changes, psychosis, dementia, & acute confusion) are common in elderly pts w/ PD - Pts w/ PD experience sleep disturbances; This may be r/t depression, dementia, or meds - Auditory & visual hallucinations have also been reported in PD & may be a/w depression, dementia, lack of sleep, or adverse effects of meds - Hypokinesia (abnormally diminished movement) is also common & may appear after the tremor; The freezing phenomenon refers to a transient inability to perform active movement & is thought to be an extreme form of bradykinesia - Pt tends to shuffle & exhibits a decreased arm swing; As dexterity declines, micrographia (small handwriting) develops; The face becomes increasingly mask-like & expressionless, & the frequency of blinking decreases - Dysphonia (soft, low-pitched, & less audible speech) may occur due to weakness of the muscles responsible for speech & paralysis of soft palate resulting in a nasal-sounding speech; In many cases, pt develops dysphagia, begins to drool, & is at risk for choking & aspiration - Complications a/w PD are common & are typically r/t disorders of movement; As the disease progresses, pts are at risk for respiratory & urinary tract infection, skin breakdown, & injury from falls - The adverse effects of meds used to treat the sx's are a/w numerous complications, like dyskinesia & orthostatic hypotension - Early dx can be difficult, b/c pts rarely are able to pinpoint when the sx's started; Often, a family member notices a change such as stooped posture, a stiff arm, a slight limp, tremor, or slow, small handwriting - The medical hx, presenting sx's, neurologic exam, & response to pharmacologic management are carefully evaluated when making the dx - Currently, the disease is dx'd clinically from pt's hx & the presence of 2 of the 4 cardinal manifestation

Alzheimer's Disease: Medical & Nursing Management (Caregiver Burden)

- The emotional burden on the families of pts w/ AD is enormous; The physical health of pt is often very stable, & mental degeneration is gradual - Family members are faced w/ numerous difficult decisions (e.g. when pt should stop driving, when to assume responsibility for pt's financial affairs) - Aggression & hostility exhibited by pt are often misunderstood by families or caregivers, who feel unappreciated, frustrated, & angry; Feelings of guilt, nervousness, & worry contribute to caregiver fatigue, depression, & family dysfunction - In some cases, caregivers themselves can become so fatigued as a result of the stress of care giving that self-neglect or neglect or abuse of pt can occur--This has been documented in home situations as well as in institutions - Respite care is a commonly provided service in which caregivers can get away from the home for short periods while someone else tends to the needs of the pt

Alzheimer's Disease: Medical & Nursing Management

- The primary goal in medical management is to manage cognitive & behavioral sx's - There is NO cure & no way to slow the progression of the disease - Behavioral problems such as agitation & psychosis can be managed by behavioral & psychosocial therapies--Associated depression & behavioral problems can also be treated w/ antidepressants & the newer atypical neuroleptics - Nursing interventions for AD are aimed at promoting pt function & independence of as long as possible

Nursing Process: The Patient with Epilepsy & Seizures (Nursing Interventions)--Improving Coping Mechanisms

- The social, psychological, & behavioral problems that frequently accompany epilepsy can be more of a disability than the actual seizures - Epilepsy may be accompanied by feelings of stigmatization, alienation, depression, & uncertainty; Pt must cope w/ the constant fear of a seizure & the psychological consequences - Adults face potential issues like the burden of finding employment, restrictions on the ability to drive, concerns about relationships & childbearing, insurance problems, & legal barriers; Alcohol abuse may complicate matters - Family reactions may vary from outright rejection of the person w/ epilepsy to overprotection; As a result, many people w/ epilepsy are at risk for psychological & behavioral problems - Counseling assists pt & family to understand the condition & the limitations it imposes; Social & recreational opportunities are necessary for good mental health - Nurses can improve the quality of life for pts w/ epilepsy by teaching them & their families about sx's & their management

Alzheimer's Disease: Medical & Nursing Management (Improving Communication)

- To promote pt's interpretation of messages, nurse should remain unhurried & reduce noises & distractions - Use of clear, easy-to-understand sentences to convey messages is essential, b/c pts frequently forget the meaning of words or have difficulty organizing & expressing thoughts - In the earlier stages of AD, lists a&d simple written instructions that serve as reminders may be helpful; In later stages, pt may be able to point to an object or use nonverbal language to communicate; Tactile stimuli, like hugs or hand pats, are usually interpreted as signs of affection, concern, & security

Multiple Sclerosis: Nursing Management (Improving Sensory & Cognitive Function)

- Vision: an eye patch or a covered eyeglass lens may be used to block the visual impulses of 1 eye if the pt has diplopia; Prisms glasses may be helpful for pts ho are confined to bed & have difficulty reading in the supine position; Those unable to read regular-print material are edible for free "talking book" services or may obtain large-print or audio books from local libraries - Cognition & Emotional Responses: cognitive impairment & emotional lability occur early in MS in some pts & may impose numerous stresses on pt & family; Some patients w/ MS are forgetful & easily distracted; Pts adapt to illness in a variety of ways, including denial, depression, withdrawal, & hostility; Emotional support assists pts & their families to adapt to the changes & uncertainties a/w MS & to cope w/ disruption in their lives; Pt is assisted to set meaningful & realistic goals, to remain as active as possible, & to keep up social interests & activities-- Hobbies may help pt's morale & provide satisfying interests if the disease progresses to the stage at which formerly enjoyed activities can no longer be pursued; The family should be made aware of the nature & degree of cognitive impairment; The environment is kept structured, & lists & other memory aids are used to help pt w/ cognitive changes to maintain a daily routine; The OT can be helpful in formulating a structured daily routine - Strengthening Coping Mechanisms: dx of MS is always distressing to pt & family; They need to know that no 2 pts w/ MS have identical sx's or courses of illness; MS affects people who are often in a productive stage of life & concerned about career & family responsibilities; Family conflict, disintegration, separation, & divorce are not uncommon; Often, very young family members assume the responsibility of caring for a parent w/ MS--Nursing interventions in this area include alleviating stress & making appropriate referrals for counseling & support to minimize the adverse effects of dealing w/ chronic illness; Nurse, mindful of these complex problems, initiates home care & coordinates a network of services, including social services, ST, PT, & homemaker services; To strengthen pt's coping skills, as much info as possible is provided; Pts need an updated list of available assistive devices, services, & resources; Coping through problem solving involves helping pt define the problem & develop alternatives for its management; Careful planning & maintaining flexibility & a hopeful attitude are useful for psychological & physical adaptation