Chapter 44 Nursing Care of Patients with Neurologic Disorders Learning Outcomes 1. Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders. 2. Describe the pathophysiology and manifestations of peripheral nervous system disorders, and outline the interprofessional care and nursing care of patients with these disorders. 3. Describe the pathophysiology and manifestations of cranial nerve disorders, and outline the interprofessional care and nursing care of patients with these disorders. Key Concepts I. Degenerative Neurologic Disorders A. Dementia: Cognitive decline caused by any disorder that permanently damages areas of the brain necessary for memory and learning 1. Results from the death of neurons and/or the loss of communication among the cells 2. Diagnosis depends on the presence of two or more deficits in the following cognitive abilities: a) Memory loss b) Ability to generate coherent speech or understand spoken or written language c) Ability to recognize or identify objects, assuming intact sensory function d) Ability to execute motor activities, assuming intact motor abilities, sensory function, and comprehension of the required task e) Ability to focus and pay attention f) Ability reason and problem solve 3. The decline in cognitive abilities must be severe enough to interfere with daily life. 4. Causes: Alzheimer disease, vascular dementia, Parkinson disease, normal pressure hydrocephalus, Creutzfeldt-Jakob disease, metabolic disorders, medications, poisoning, chronic traumatic encephalopathy (CTE), and anoxia 5. Risk factors: Aging, a family history of dementia, smoking and alcohol use, atherosclerosis, high cholesterol, elevated plasma homocysteine levels, diabetes mellitus, and Down syndrome B. The patient with Alzheimer disease 1. Form of dementia characterized by progressive, irreversible deterioration of general intellectual functioning 2. 80% of dementia due to AD 3. Cause unknown, develops from interaction of multiple factors 4. Early onset: Under 65; late onset: Over 65 Copyright © 2020 by Pearson Education, Inc. Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition a) Rare genetic variation causes some cases of early onset. 5. Pathophysiology a) Atrophy of the cortical area of the brain and loss of neurons, especially in the parietal and temporal lobes b) Theories about cause and development: Amyloid hypothesis, tau hypothesis, and vascular hypothesis c) Neuritic plaques: Groups of nerve cells that degenerate and clump around an amyloid core and disrupt nerve impulses (1) Consist primarily of insoluble deposits of beta-amyloid d) Neurofibrillary tangles: Found in the cytoplasm of abnormal neurons, composed of fibrous proteins wound around each other; disrupt communication between neurons (1) Contain the protein tau 6. Risk factors a) Age, head trauma, inflammatory factors, oxidative stress, low educational level, lack of mental stimulation, migraines, and heavy smoking and alcohol consumption b) Gene mutation 7. Stages and manifestations a) Stage 1: No cognitive impairment b) Stage 2: Very mild decline c) Stage 3: Mild cognitive decline d) Stage 4: Moderate cognitive decline e) Stage 5: Moderately severe cognitive decline (1) Some assistance with ADLs is essential. (2) Usually retain essential knowledge about themselves and family (3) Confusion about date, day of the week, etc. f) Stage 6: Severe cognitive decline (1) Emergence of personality changes (2) Extensive help with ADLs needed (3) May forget most personal history g) Stage 7: Very severe cognitive decline (1) Loss of ability to respond to environment, speak, and control movement 8. Interprofessional care a) Diagnosis: No specific test (1) Ruling out causes for manifestations: Medications, depression, infection, hypothyroidism, dehydration, heart disease, stroke, and chronic obstructive respiratory disease (2) Mental status tests: Folstein Mini Mental State Examination, Alzheimer Disease Assessment Scale, draw a clock Copyright © 2020 by Pearson Education, Inc. Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition (3) Only completely confirmed in postmortem examination b) Medications (1) Acetylcholinesterase inhibitors (AChEls) and N-methyl-D-aspartate (NMDA): May slow progression of cognitive decline (2) Medications for manifestations: Sleep disturbances, depression, agitation, delusions, and aggression c) Nutrition (1) Mediterranean diet has neuroprotective benefits. d) Integrative therapies (1) Huperzine A, a traditional Chinese medicine (2) Coenzyme Q10, an antioxidant (3) Supplements: Zinc, ginkgo biloba, B vitamins, vitamin E (4) Therapies: Massage, art, music, sound, dance, and pet therapy 9. Nursing care a) Assessment (1) Health history (2) Physical assessment b) Priorities of care (1) Falls prevention (2) Memory loss (3) General safety considerations c) Diagnoses, outcomes, and interventions (1) Reduce risk for harm (a) Recommend a medication box labeled with days and times (b) Provide continuity in nursing staff (c) Repeat explanations simply and as needed (2) Relieve anxiety (a) Monitor for early behaviors of fatigue and agitation (b) Remove from situations that increase anxiety (c) Keep daily routine as consistent as possible (d) Schedule rest periods or quiet times throughout the day and provide quite activities (e) Assess for decreased oxygen, infections, fatigue, constipation, and electrolyte imbalance if unyielding anxiety (f) Use therapeutic touch or gentle hand massage (3) Instill hope (a) Assess the patient’s and family’s response to the diagnosis and understanding of AD (b) Teach about the disorder (c) Support positive family bonds (d) Encourage the patient to make as many decisions as possible Copyright © 2020 by Pearson Education, Inc. Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition (e) Encourage the family and patient to use coping mechanisms that previously helped (4) Reduce caregiver stress (a) Teach the caregivers self-care techniques (b) Have the caregivers list and regularly take part in physical activities they enjoy (c) Refer the caregivers to local AD support groups, Meals on Wheels, home health, respite care, and other community services (d) Ensure the family knows of availability of hospice care for end stages 10. Transitions of care a) Discuss: Support groups; care that matches the patient’s coping; regular rest periods; and plan care for the caregiver b) Refer to resources C. The patient with multiple sclerosis 1. Chronic demyelinating disease of the CNS 2. Pathophysiology a) Believed to occur as a result of an autoimmune response in a genetically susceptible person b) Plaques destroy myelin sheaths around nerves, disrupt nerve impulses c) Plaques usually in white matter and may extend to gray matter d) First stage: Development of small inflammatory lesions e) Second stage: Lesions extend and consolidate as gliosis and demyelination occurs. f) Courses: Relapsing–remitting, primary progression, secondary progression, and progressive-relapsing 3. Risk factors a) Genetics, geographic location, diagnosis of other autoimmune disorders (type 1 diabetes), low levels of vitamin D, obesity, smoking, and high salt intake 4. Manifestations a) Fatigue b) Pain c) Visual deficits d) Cognitive dysfunctions e) Mood alterations f) Weakness and/or numbness in one or both extremities g) Upper motor neuron involvement h) Bladder dysfunctions i) Bowel dysfunction j) Sexual dysfunction Copyright © 2020 by Pearson Education, Inc. Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition 5. Complications a) Increased risk for falls 6. Interprofessional care a) Diagnosis (1) Based on manifestations and patterns of exacerbation and remission (2) MRI and CT scans: Can detect lesions (3) CSF: Indicates immune response, shows elevated levels of immunoglobulin G (IgG) b) Medications (1) During acute exacerbations (a) Combination of adrenal corticosteroid hormone (ACTH) and glucocorticoids (b) Immunosuppressive agents (2) To reduce exacerbations in relapsing courses (a) Interferon and glatiramer acetate (b) Fingolimod (Gilenya) (3) For manifestations (a) Anticholinergics: For bladder spasticity (b) Cholinergics: For bladder flaccidity (c) Amantadine (Symmetrel): For fatigue c) Nutrition and fluids (1) Inability to ambulate and depression can lead to overweight condition (2) Inability to prepare and eat food may occur with progression, dysphagia may occur, diet must be accommodated d) Rehabilitation (1) Stretching exercises, gait training, braces, splints: For spasticity (2) Collaborators: Speech therapists, occupational therapy and occupational counseling, urologist, and respiratory therapist e) Surgery (1) Tendon release procedures : For foot drop from severe plantar flexion 7. Nursing care a) Assessment (1) Health history (2) Physical assessment b) Diagnoses, outcomes, and interventions (1) Prevent fatigue (a) Assess degree of fatigue, identify contributing factors (b) Set priorities for activities and include rest periods (c) Advise to avoid temperature extremes (d) Provide interventions to relieve pain (e) Refer to appropriate specialists to manage fatigue Copyright © 2020 by Pearson Education, Inc. Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition (2) Encourage self-care (a) Assist with bathing, toileting, dressing, grooming, and feeding from minimal guidance to complete dependence 8. Transitions of care a) Discuss: Treatment and side effects; ongoing care from interprofessional team b) Refer to helpful resources D. The patient with Parkinson disease 1. Progressive, degenerative disorder of basal ganglia function characterized by tremor, muscle rigidity, bradykinesia, and postural instability 2. Cause is unknown; there is a genetic link; environmental factors play a role 3. Pathophysiology a) Decrease in production of dopamine b) Relative excess of acetylcholine 4. Manifestations a) Early: Patients complain of being tired and moving more slowly, may experience impaired sense of smell and pain b) Tremor (1) Begins unilateral, progresses to bilateral, progressive impairment hinders activities that require dexterity and fine muscle control c) Rigidity and bradykinesia (1) Rigidity can cause muscle cramps in toes or hands, stiffness, heaviness, or aching in muscles, may cause flexion contractures (2) Bradykinesia: Difficulty in starting, continuing, or coordinating movements (a) Patients have staring gaze with minimal change in expression, or remain still for long periods of time d) Abnormal posture (1) Postural fixation: Stooped, leaning forward position (2) Equilibrium: Increased risk of injury from falls e) Autonomic and neuroendocrine effects (1) Elimination problems (2) Orthostatic hypotension (3) Eczematous skin changes and seborrhea f) Mood and cognition (1) Depression: Occurs in 50% (2) Dementia: Occurs in 20%, similar manifestations to AD (3) Bradyphrenia: Slow thinking and decreased ability to form thoughts or plan g) Sleep disturbances (1) From excess acetylcholine and muscle rigidity h) Interrelated effects Copyright © 2020 by Pearson Education, Inc. Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition (1) Constipation 5. Complications a) Paranoia, hallucinations, impaired communications, falls, infections, malnutrition, altered sleep patterns, skin breakdown and pressure ulcers, depression and social isolation 6. Interprofessional care a) Diagnosis: Based on manifestations b) Medications (1) Dopamine precursors (a) Carbidopa, levodopa, levodopa-carbidopa (Parcopa, Sinemet) (b) Help balance dopamine/acetylcholine imbalance (2) Monoamine oxidase B inhibitors (a) Selegiline (Eldepryl, Zelapar) and rasagiline (Azilect) (b) Selectively inhibits the enzyme that inactivates dopamine in the brain (3) Dopamine agonists (a) Bromocriptine (Parlodel) and pramipexole (Mirapex) (b) Mimic role of dopamine in the brain (4) Catechol-O-methyltransferase (COMT) inhibitors (a) Tolcapone (Tasmar) and entacapone (Comtan) (b) Inhibit dopamine metabolism (5) Anticholinergics (a) Trihexyphenidyl (Artane) and benzotropine (Cogentin) (b) Block the excitatory action of the neurotransmitter acetylcholine c) Nutrition (1) Fluids (2) Avoid high-protein diets d) Surgery (1) Deep brain stimulation (DBS): For those with advanced tremors (a) Pacemaker-like neurostimulator is implanted in brain, connected to pulse generator, pulses interfere with brain’s electrical signals that cause manifestations (2) Gene therapy, cell replacement therapy, and vaccines (a) Investigational treatment e) Integrative therapies (1) Exercise 7. Nursing care a) Assessment (1) Health history (2) Physical examination Copyright © 2020 by Pearson Education, Inc. Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition b) Diagnoses, outcomes, and interventions (1) Promote physical mobility (a) Suggest referral to physical therapist, request that caregivers learn how to assist with ROM exercises (b) Ask caregivers to ambulate patient at least four times a day if possible (c) Recommend assistive devices (d) Modify environment for safety and reduction of fall risks (2) Promote verbal communication (a) Assess current communication abilities in speech, hearing, and writing (b) Develop methods of communication appropriate to coordination abilities (c) Suggest referral to a speech pathologist (d) Remind patient to speak more loudly, if possible (3) Promote adequate nutrition (a) Assess nutritional status (b) Teach caregivers how to prepare foods of appropriate consistency (c) Weight weekly (d) Teach eating methods to decrease tremors (e) Encourage diet that is high in bulk and fluids (4) Manage sleep pattern (a) Assess sleep pattern and existing conditions that may affect sleep (b) Explain the disease process and the effects on sleep (c) Review patient’s medication (d) Teach how to modify lifestyle activities that affect sleep and mobility 8. Transitions of care a) Discuss: Realistic expectations, equipment suppliers, home environment, gait training and exercises, increased fluid intake, stool softeners, swallowing during eating and taking medications, and foods that can easily swallow b) Refer to specialists and helpful resources E. The patient with Huntington disease 1. Progressive, degenerative, inherited neurologic disease characterized by increasing dementia and chorea a) Autosomal-dominant inherited 2. Pathophysiology a) Destruction of cells in the upper and lower motor neurons b) Other areas of the brain may selectively atrophy c) Several neurotransmitters are decreased, including acetylcholine d) Excess of dopamine relative to acetylcholine causes excessive, uncontrolled movement 3. Manifestations Copyright © 2020 by Pearson Education, Inc. Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition a) Motor effects (1) Early: Restlessness, fidgety feeling, minor gait changes, posture and positioning disturbances, inability to keep the tongue from protruding, and slurred speech (2) Later: Chorea, facial grimacing, dysphagia, unintelligible speech, and impaired diaphragmatic movement b) Psychosocial effects (1) Early: Irritability, outbursts of rage alternating with euphoria, and depression (2) Late: Decreasing memory, loss of cognitive skills, and eventual dementia 4. Interprofessional care a) Diagnosis b) Prognosis is poor c) Nursing care (1) Teaching about the disease (2) Psychologic support (3) Genetic counseling (4) Immobility (5) Altered nutrition (6) Self-care deficits F. The patient with amyotrophic lateral sclerosis 1. Rapidly progressive and fatal degenerative neurologic disease characterized by weakness and wasting of muscles under voluntary control, without any accompanying sensory changes 2. 90–95% of cases occur randomly with no associated risk factors; 5–10% are inherited. 3. Pathophysiology a) Death of the motor neurons results in axonal degeneration, demyelination, glial proliferation, and scarring along the corticospinal tract b) Pathogenesis is being researched. 4. Manifestations a) Early: Spastic, weak muscles, increased deep tendon reflexes, muscle flaccidity, and slurred speech b) Atrophy ensues, paralysis results c) Eventually requires ventilatory support to breathe 5. Interprofessional care a) Diagnosis (1) Based on manifestations and tests to rule out other diseases b) Medications Copyright © 2020 by Pearson Education, Inc. Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition (1) Riluzole (Rilutek), an antiglutamate: Inhibits the presynaptic release of glutamic acid in the CNS and protects neurons against the excitotoxicity of glutamic acid 6. Nursing care a) Diagnoses, outcomes, and interventions (1) Promote physical mobility (a) Assess current condition for baseline parameters (b) Assess skin, provide skin care, and obtain alternating-pressure mattress (c) Institute active ROM exercises and/or perform passive ROM exercises (d) Maintain positive nitrogen balance and hydration status (e) Monitor for manifestations of infection (2) Promote effective breathing (a) Obtain a baseline assessment of breathing pattern, air movement, and oxygen saturation (b) Turn at least every 2 hours (c) Elevate the head of the bed at least 30° (d) Monitor temperature and lung sounds routinely, obtain sputum culture as indicated 7. Transitions of care a) Explain disease process, expected course, and prognosis b) Referral to social worker, home health agency, dietician, physical, speech, and occupational therapists c) As disease progresses, focus on preventing complications, and teach family measures d) Much consideration to psychosocial concerns II. Peripheral Nervous System Disorders A. The patient with myasthenia gravis 1. Chronic autoimmune neuromuscular disorder characterized by fatigue and severe weakness of skeletal muscles 2. Pathophysiology a) Antibodies destroy or block neuromuscular junction receptor sites, resulting in a decreased number of acetylcholine receptors b) Decrease in the muscle’s ability to contract despite a sufficient amount of acetylcholine c) Thymus believed to be a source of an autoantigen that triggers autoimmune response d) Sometimes associated with thyrotoxicosis, rheumatoid arthritis, and lupus erythematosus 3. Manifestations a) Ocular and facial: Ptosis, diplopia, facial weakness, dysphagia, and dysarthria b) Musculoskeletal: Weakness, fatigue, decreased function of hands, arms, legs, and neck Copyright © 2020 by Pearson Education, Inc. Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition c) Respiratory: Weakening of intercostal muscles, decrease in diaphragm movement, breathlessness and dyspnea, poor gas exchange d) Nutritional: Inability to chew and swallow, decreased ability to move tongue, and impairment of fine motor movements 4. Complications a) Aspiration and pneumonia b) Myasthenic crisis: Sudden exacerbation of motor weakness putting the patient at risk of respiratory failure and aspiration (1) Due to undermedication, missed doses of medication, or a developing infection (2) Manifestations: Tachycardia, tachypnea, severe respiratory distress, dysphagia, restlessness, impaired speech, and anxiety c) Cholinergic crisis: Result of overdosage with the anticholinesterase (cholinergic) medications (1) Manifestations: GI manifestations, severe muscle weakness, vertigo, and respiratory distress are signs of cholinergic crisis. 5. Interprofessional care a) Diagnosis (1) Tensilon test: Injection of edrophonium chloride (Tensilon), results in significant improvement of muscle strength that lasts a few minutes (2) Single-fiber electromyography (3) Serum assay of circulating acetylcholine receptor antibodies: Increases b) Medications (1) Anticholinesterases (a) Neostigmine (Prostigmin), , pyridostigmine (Mestinon, Regonol) (b) Enhance the effects of acetylcholine at the remaining skeletal muscle receptors (2) Immunosuppression with glucocorticoids: To improve muscle strength c) Surgery (1) Thymectomy: For patients younger than 60 (a) Transcervical approach versus transsternal approach (b) Tapered with steroid therapy (c) Nursing care: Preventing complications, controlling pain d) Plasmapheresis (1) Goal to remove antiacetylcholine receptor antibodies 6. Nursing care a) Diagnoses, outcomes, and interventions (1) Maintain effective airway clearance (a) Assist with turning, deep breathing, and coughing every 2 hours (b) Place in semi-Fowler position Copyright © 2020 by Pearson Education, Inc. Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition (c) Maintain hydration status and monitor for dehydration (d) Monitor lung sounds, respiration status (2) Reduce risk of aspiration (a) Assess ability to manage various consistencies of foods (b) Speech therapy consultation (c) Plan meals to promote medication effectiveness (d) Have the patient eat slowly, using small bites of food (e) Give cues while eating (f) Teach caregivers the Heimlich maneuver and suctioning (g) Monitor lung sounds, respirations, and pulse oximetry 7. Transitions of care a) Discuss: Treatment, realistic expectations, methods to avoid fatigue and undue stress, and birth control measures b) Refer to support groups and helpful resources B. The patient with Guillain-Barré syndrome 1. Acute inflammatory demyelinating disorder of the PNS characterized by an acute onset of motor paralysis (usually ascending) 2. Precipitating events: Respiratory or gastrointestinal viral or bacterial infection 1–3 weeks prior to the onset of manifestations, surgery, viral immunizations, and other viral illnesses a) Sometimes no precipitating event 3. Pathophysiology a) Destruction of myelin sheaths results in poor conduction of nerve impulses 4. Manifestations a) Acute stage: Severe and rapid weakness, progresses to quadriplegia and respiratory failure; decreased deep tendon reflexes; decreased vital capacity; paresthesias, numbness; and pain b) Stabilizing/plateau stage: “Leveling off” of symptoms; 2–3 weeks after onset c) Recovery stage: May take several months to 2 years; improvement of symptoms; muscle strength and function return 5. Interprofessional care a) Diagnosis: Based on manifestations, history of recent viral infection, elevated CSF proteins, EMG studies (1) CT scan, lumbar punctures, and nerve conduction study b) Medications (1) Antibiotics for prophylaxis (2) Morphine for muscle pain (3) Anticoagulation therapy to prevent thromboembolic complications Copyright © 2020 by Pearson Education, Inc. Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition (4) Vasopressors for hypotension c) Nutrition and fluids (1) Maintaining positive nitrogen balance, ensuring sufficient fluid intake and electrolyte balance, and ensuring recommended caloric intake (2) Total parenteral nutrition in case of swallowing problems d) Plasmapheresis (1) Can be beneficial within first two weeks of syndrome development e) Physical and occupational therapy (1) Long term and crucial to recovery (2) Have to relearn walking (3) Controlling pain important 6. Nursing care a) Diagnoses, outcomes, and interventions b) Control acute pain (a) Listen to description of pain; determine triggers and/or pattern (b) Use complementary therapies to relieve pain (c) Provide analgesics as indicated (d) Monitor for side effects of analgesics (2) Promote good skin integrity (a) Inspect and provide skin care every 2 hours (b) Pad bony prominences (c) Use an alternating-pressure mattress (d) Monitor for incontinence 7. Transitions of care a) Teach disease process, include patient and family in treatment decisions b) Teach to avoid complications c) Refer to appropriate specialists for rehabilitation III. Cranial Nerve Disorders A. The patient with trigeminal neuralgia 1. Severe, brief, repetitive attacks of lightening-like or throbbing pain, occurring along the distribution of a spinal or cranial nerve 2. Pathophysiology a) Follows vascular compression and demyelination of the trigeminal nerve b) Contributing factors include trauma, dental or jaw infections, flulike illnesses, aneurysm, tumor, and MS c) Pain episodes triggered by stimulation of trigger zones on face 3. Manifestations Copyright © 2020 by Pearson Education, Inc. Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition a) Brief (lasting a few seconds to a few minutes), repetitive episodes of sudden severe facial pain (1) May occur as often as hundreds of times a day to as infrequently as a few times a year 4. Interprofessional care a) Diagnosis: Based on manifestations b) Medications (1) Tricyclic anticonvulsant carbamazepine (Tegretol) (2) Anticonvulsants carbamazepine (Tegretol ) or gabapentin (Neurontin) or the skeletal muscle relaxant baclofen (Lioresal) c) Surgery (1) Rhizotomy: Surgical severing of a nerve root (a) Open and closed procedures 5. Nursing care a) Diagnoses, outcomes, and interventions (1) Control acute pain (a) Identify factors that trigger an attack (b) Determine usual response to pain (c) Assess factors that affect pain tolerance (d) Monitor effects of medications prescribed (2) Promote balanced diet (a) Monitor dietary intake and weight at each visit (b) Discuss temperature and consistency of foods (c) Suggest chewing on unaffected side of mouth (d) Tube feedings may be necessary 6. Transitions of care a) Teach disease process, medications, and ways to reduce incidents of pain B. The patient with Bell Palsy 1. Disorder of the seventh cranial (facial) nerve, characterized by unilateral weakness of the facial muscles 2. May occur as a distinct classic disease or may accompany other diseases such as GuillainBarré syndrome, tumor, Lyme disease, or stroke 3. Pathophysiology a) Believed to be caused by herpes simplex virus type 1 and herpes zoster virus 4. Manifestations a) Onset is sudden. b) Pain behind ear or along jaw may accompany symptoms. c) Face becomes distorted. Copyright © 2020 by Pearson Education, Inc. Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition d) Paralysis varies. 5. Interprofessional care a) No specific diagnostic test or treatments b) Medications: Antiviral drugs combined with anti-inflammatory drug c) Physical therapy d) Moist heat to decrease pain 6. Nursing care a) Interventions (1) Use artificial tears (2) Massage with warm, moist heat (3) Soft diet (4) Facial exercises 7. Transitions of care a) Healthy diet b) Daily exercise Chapter Highlights A. Dementia involves impairment in short- and long-term memory; impairment in language, motor activity, recognition, and/or abstract thinking; and a clinical course characterized by gradual onset and continuing cognitive decline. B. Alzheimer Disease (AD) is progressive and relentless and is characterized by cognitive and functional decline. The disease is characterized by atrophy of brain tissue, loss of neurons, neurofibrillary tangles, and amyloid plaques. There are no effective treatments for preventing AD, although pharmacologic and nonpharmacologic therapies may slow its course. Education of caregivers addresses burdens and expectations and provides instruction regarding community resources. The goal is to maximize the environment to the patient’s functional abilities and safety needs. C. Multiple sclerosis (MS) is an autoimmune, demyelinating disease of the central nervous system. MS is multifactorial, with genetic and environmental factors linked to its incidence. Exposure to UVB light and exposure to the Epstein-Barr virus have both been implicated as environmental factors that interact with genes to lead to the onset of MS. The loss of myelin leads to axon dysfunction, which slows and distorts nerve impulses. Medications are used to slow the progression of the disease, decrease the number of exacerbations, and treat manifestations. D. Parkinson disease (PD) is a progressive degenerative neurologic disease characterized by tremor, muscle rigidity, and bradykinesia. The loss of voluntary motor control is the result of pathologic processes resulting in a decrease of dopamine (an inhibitory neurotransmitter) so that it can no longer inhibit acetylcholine (an excitatory neurotransmitter). Medications Copyright © 2020 by Pearson Education, Inc. Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition E. F. G. H. I. to treat manifestations include MAO inhibitors, dopaminergics, dopamine agonists, and anticholinergics. Huntington disease (chorea) is a progressive, degenerative inherited neurologic disease characterized by increasing dementia and chorea. Amyotrophic lateral sclerosis (ALS) is a rapidly progressive and fatal degenerative motor neuron disease characterized by weakness and wasting of voluntary control muscles, but without sensory or cognitive changes. The patient eventually loses the ability to communicate and breathe. Myasthenia gravis (MG) is a chronic autoimmune PNS disorder characterized by fatigue and severe skeletal muscle weakness. It results from a decreased number of acetylcholine receptors at the neuromuscular junction, so muscles are unable to contract. Lifethreatening emergencies include myasthenic crisis (sudden increase in motor weakness) and cholinergic crisis (from an overdose of the anticholinesterase medications used to treat MG). Guillain-Barré syndrome (GBS) is an acute inflammatory demyelinating disease of the PNS characterized by an acute onset of flaccid motor paralysis that begins in the lower extremities and ascends to involve the upper extremities, torso, and cranial nerves. Paralysis of intercostal and diaphragmatic muscles often necessitates ventilatory assistance. The progressive phase lasts up to 4 weeks, followed by recovery, which takes from 6 months to 2 years. Cranial nerve disorders include trigeminal neuralgia (TN) and Bell palsy. TN is a chronic disorder of cranial nerve V and causes severe facial pain. Bell palsy is an acute disorder of cranial nerve VII, characterized by unilateral paralysis of the facial muscles. SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE Have a family member of a patient with Alzheimer disease address the class regarding the experience of caring for a patient with Alzheimer disease in the home. In class, have students share what they have learned about stages of Alzheimer disease and nursing care strategies pertinent to each stage. Have the class access the internet for information regarding support groups for each of the disorders discussed. SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE Assign students to care for clients with AD, MS, or PD. Have the students discuss the care required during postclinical conference. Copyright © 2020 by Pearson Education, Inc. Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO Have students review the medical records of clinical patients for medications that are commonly administered to people with chronic neurologic disorders. Require students to develop medication administration information sheets on the medications. Include information regarding dose, side effects, administration implications, and teaching required. Have the class access the internet for information regarding support groups for each of the disorders discussed. SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO Assign students to care for clients with MG if possible. If not available, assign students to observe the plasmapheresis procedure. SUGGESTIONS FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE Using anatomic models, discuss the procedures to treat trigeminal neuralgia. Discuss the nursing implications of care of the postoperative patient. Have the class access the internet for information regarding support groups for each of the disorders discussed. SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE Assign students to care for a client with trigeminal neuralgia or Bell palsy. If not available, have the students creating a teaching tool that supports self-care needs of the client with these disorders. Copyright © 2020 by Pearson Education, Inc. Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition