Chapter 39 Care of Patients with Problems of the Central Nervous System: The Brain Copyright © 2021, Elsevier Inc. All Rights Reserved. Concepts The priority concepts in this chapter are Cognition Mobility The interrelated concept in this chapter is Pain Infection Copyright © 2021, Elsevier Inc. All Rights Reserved. Alzheimer’s Disease Pathophysiology Overview Most common type of dementia Microscopic changes of the brain – neurofibrillary tangles, neuritic plaques, beta amyloid Neurotransmitter abnormalities Copyright © 2021, Elsevier Inc. All Rights Reserved. Alzheimer’s Disease: Etiology and Genetic Risk Age Gender Genetics Copyright © 2021, Elsevier Inc. All Rights Reserved. Alzheimer’s Disease: Incidence and Prevalence Higher incidence and prevalence after age 65 Can affect anyone older than age 40 5.7 million affected in U.S. (over 65 years old) Copyright © 2021, Elsevier Inc. All Rights Reserved. Alzheimer’s Disease: Health Promotion and Maintenance No proven way to prevent AD Chronic health problems may contribute Diet Exercise Stop smoking and drinking Copyright © 2021, Elsevier Inc. All Rights Reserved. Alzheimer’s Disease: Assessment: Recognize Cues (1 of 2) History Physical assessment Onset, duration, progression, course of symptoms Functional status Stages Attention, concentration, judgment, perception, learning memory, communication and language, information processing Psychosocial assessment Copyright © 2021, Elsevier Inc. All Rights Reserved. Alzheimer’s Disease: Assessment: Recognize Cues (2 of 2) Laboratory and imaging assessment Brain tissue examination at autopsy is only definitive diagnosis Genetic testing CT MRI Copyright © 2021, Elsevier Inc. All Rights Reserved. Alzheimer’s Disease: Analysis: Analyze Cues & Prioritize Hypotheses Decreased memory and cognition due to neuronal changes in the brain Potential for injury or falls due to wandering or inability to ambulate independently Potential for elder abuse by caregivers due to the patient's prolonged progression of disability and the patient's increasing care needs Copyright © 2021, Elsevier Inc. All Rights Reserved. Alzheimer’s Disease: Planning and Implementation: Generate Solutions and Take Action Managing memory and cognitive dysfunction Preventing injuries or falls Preventing elder abuse Copyright © 2021, Elsevier Inc. All Rights Reserved. Alzheimer’s Disease: Care Coordination and Transition Management Home care management Self-management education Respite care Preparation in case patient becomes agitated Teach family about drug therapy Maintain mobility as long as possible Health care resources Alzheimer’s Association Copyright © 2021, Elsevier Inc. All Rights Reserved. Alzheimer’s Disease: Evaluation: Evaluate Outcomes Maintain memory and cognition for as long as possible and increase quality of life Remain injury-free Manage caregiver stress to prevent elder abuse Copyright © 2021, Elsevier Inc. All Rights Reserved. Mobility Concept Exemplar: Parkinson Disease (PD) Pathophysiology Overview Progressive neurodegenerative disorder Four cardinal symptoms • Tremor • Muscle rigidity • Bradykinesia • Postural instability Copyright © 2021, Elsevier Inc. All Rights Reserved. Parkinson Disease: Etiology and Genetic Risk Environmental and genetic factors Exposure to chemicals and metals Older than 40 years old Familial tendency Copyright © 2021, Elsevier Inc. All Rights Reserved. Parkinson Disease: Incidence and Prevalence 60,000 new cases annually in people over 50 years old 1 million live with PD 50% more men than women Copyright © 2021, Elsevier Inc. All Rights Reserved. Parkinson Disease: Assessment: Noticing History Physical assessment When symptoms started Resting tremors in upper extremities Rigidity assessment Facial expression (“masklike”) Emotional changes Speech changes Bowel and bladder changes Laboratory and imaging assessment No specific diagnostic tests May do CSF, MRI, or SPECT Copyright © 2021, Elsevier Inc. All Rights Reserved. Parkinson Disease The image to the right portrays the masklike facial expression typical of clients with Parkinson disease. Copyright © 2021, Elsevier Inc. All Rights Reserved. Parkinson Disease: Analysis: Analyze Cues & Prioritize Hypotheses Decreased mobility (and possible self-care deficit) related to muscle rigidity, tremors, and postural/gait changes Impaired cognition due to neurotransmitter changes in the brain Copyright © 2021, Elsevier Inc. All Rights Reserved. Parkinson Disease: Planning and Implementation: Responding Promoting mobility Nonsurgical management Surgical management Managing cognitive dysfunction Copyright © 2021, Elsevier Inc. All Rights Reserved. Parkinson Disease: Care Coordination and Transition Management Home care preparation Self-management education Health care resources Copyright © 2021, Elsevier Inc. All Rights Reserved. Parkinson Disease: Evaluation: Evaluate Outcomes Improve mobility to provide self-care and not experience complications of impaired mobility Maintain safety and an acceptable quality of life Copyright © 2021, Elsevier Inc. All Rights Reserved. Migraine Headache Recurrent, episodic attacks of head pain often with nausea, sensitivity to light or sound or head movement Some patients have food triggers With aura; without aura; atypical Pain management Abortive therapy APAP or NSAIDs Triptan preparations, ergotamine derivatives, isometheptene combinations Copyright © 2021, Elsevier Inc. All Rights Reserved. Seizures and Epilepsy Seizure Abnormal, sudden, excessive, uncontrolled electrical discharge of neurons within the brain that may result in a change in LOC, motor or sensory ability, and/or behavior Epilepsy Chronic disorder in which repeated unprovoked seizure activity occurs Copyright © 2021, Elsevier Inc. All Rights Reserved. Types of Seizures Tonic-clonic Myoclonic Atonic (akinetic) Partial (focal or local) Complex partial (psychomotor or temporal lobe) Copyright © 2021, Elsevier Inc. All Rights Reserved. Seizures and Epilepsy: Etiology and Genetic Risk Primary Genetics Secondary Underlying brain lesion (tumor or trauma) Metabolic disorders Acute alcohol withdrawal Electrolyte disturbances High fever Stroke Head injury Substance abuse Heart disease Copyright © 2021, Elsevier Inc. All Rights Reserved. Seizures and Epilepsy: Interprofessional Collaborative Care Assessment: Recognize Cues Number, timing, pattern of seizures Preictal phase Other medical history EEG, CT, MRI, SPECT/PET Interventions: Take Action Nonsurgical management Surgical management Copyright © 2021, Elsevier Inc. All Rights Reserved. Seizure Management Protect the patient from injury. Do not force anything into the patient's mouth. Turn the patient to the side to prevent aspiration and keep the airway clear. Remove any objects that might injure the patient. Suction oral secretions if possible without force. Loosen any restrictive clothing the patient is wearing. Do not restrain or try to stop the patient's movement; guide movements if necessary. Record the time the seizure began and ended. Copyright © 2021, Elsevier Inc. All Rights Reserved. Acute Seizure and Status Epilepticus Management Medical emergency IV-push lorazepam or diazepam, or diazepam rectal gel Copyright © 2021, Elsevier Inc. All Rights Reserved. Seizures and Epilepsy: Care Coordination and Transition Management Compliance with AEDs Social services referral Balanced diet and rest, stress-reduction Copyright © 2021, Elsevier Inc. All Rights Reserved. Meningitis Pathophysiology Overview Infection of the meninges of the brain and spinal cord, specifically the pia mater and arachnoid Types • Viral (aseptic) • Bacterial Copyright © 2021, Elsevier Inc. All Rights Reserved. Meningitis: Interprofessional Collaborative Care Assessment: Recognize Cues Neurologic and neurovascular assessment Nuchal rigidity Increased ICP Interventions: Take Action Vaccination for prevention Accurate monitoring and documentation of neurologic status Broad-spectrum antibiotics Vascular assessment Copyright © 2021, Elsevier Inc. All Rights Reserved. Case Study (1 of 6) 1. The wife of a client recently diagnosed with Alzheimer’s disease asks the nurse if there is a cure for her husband’s illness. What is appropriate nursing response? A. “Eating a balanced diet that includes lots of soy products can prevent Alzheimer’s disease.” B. “Cholinesterase inhibitor drugs can slow the progression of the disease for some clients.” C. “Removal of neuritic plaques can prevent vascular degeneration and improve brain cell function.” D. “Decreasing the levels of neurotransmitters in the brain can slow the progression of the disease.” Copyright © 2021, Elsevier Inc. All Rights Reserved. Answer to Case Study Question 1 ANS: B Cholinesterase inhibitors are approved for treating Alzheimer’s disease symptoms. They work to improve cholinergic neurotransmission in the brain by delaying the destruction of acetylcholine (ACh) by the enzyme acetylcholinesterase. This slows the onset of cognitive decline in some clients. Copyright © 2021, Elsevier Inc. All Rights Reserved. Case Study (2 of 6) The wife states that her husband is able to perform most of his own ADLs (activities of daily living), and wants to keep him safely and independently functioning in their home as long as possible. 2. To facilitate the client’s safe independence, which action will the nurse recommend? A. Ensure that door locks can be easily opened by the client. B. Take the client out often so that he can socialize with many people at once. C. Vary times for meals, bedtime, and getting up in the morning. D. Place outfits on hangers, then allow the client to choose what to wear. Copyright © 2021, Elsevier Inc. All Rights Reserved. Answer to Case Study Question 2 ANS: D Allowing the client to choose what to wear supports the client’s independence because he can still dress himself. The other responses are not appropriate strategies for clients with Alzheimer’s disease. Crowds of people would further confuse the client. Clients with Alzheimer’s disease do much better with a consistent routine. Easily unlocked doors provide easy access in case the client begins wandering. Copyright © 2021, Elsevier Inc. All Rights Reserved. Case Study (3 of 6) At a 6-month follow-up appointment, the wife states that the client occasionally has difficulty finding the correct words to use when communicating. 3. What term does the nurse use to document this assessment data? A. B. C. D. Apraxia Aphasia Anomia Agnosia Copyright © 2021, Elsevier Inc. All Rights Reserved. Answer to Case Study Question 3 ANS: C Anomia is the inability to find words. Apraxia is the inability to use words or objects correctly. Aphasia is the inability to speak or understand. Agnosia is the loss of sensory comprehension. Copyright © 2021, Elsevier Inc. All Rights Reserved. Case Study (4 of 6) At an 18-month follow-up appointment, the wife states that her husband seems depressed most of the time and has become less talkative over the past few months. 4. Which medication could be helpful for this client’s symptoms? A. B. C. D. Sertraline Amitriptyline Imipramine Desipramine Copyright © 2021, Elsevier Inc. All Rights Reserved. Answer to Case Study Question 4 ANS: A Some clients with Alzheimer’s disease develop depression and can be treated with antidepressant drugs. Selective serotonin reuptake inhibitors (SSRIs) such as paroxetine (Paxil) and sertraline (Zoloft) are usually prescribed. Copyright © 2021, Elsevier Inc. All Rights Reserved. Case Study (5 of 6) 5. The client’s wife calls the health care provider’s office to report that her husband took a walk today in a very familiar area, yet got lost and a neighbor brought him home. What safety measure will the nurse recommend? Select all that apply. A. “Consider enrollment in the Safe Return program.” B. “Obtain a medical ID bracelet the he should wear at all times.” C. “Place him in a geri-chair when you can’t be with him.” D. “Ask the health care provider about a sedative drug to keep him calm.” E. “Take him for a walk two or three times a day in different neighborhoods.” Copyright © 2021, Elsevier Inc. All Rights Reserved. Answer to Case Study Question 5 ANS: A, B, C Positive interventions for coping with restlessness and wandering include having the client wear an ID bracelet, enrolling him in a Safe Return program, and the use of a gerichair. Physical and chemical restraints such as sedatives should only be used as a last resort. Taking him for walks in different neighborhoods may increase confusion. Copyright © 2021, Elsevier Inc. All Rights Reserved. Case Study (6 of 6) During the call, the wife states that she must go out of town for 3 days to care for an elderly cousin, and she is concerned about her husband’s care. 6. Which nursing response is appropriate? A. “Can you return home sooner than 3 days?” B. “Why are you choosing to care for your cousin instead of your spouse?” C. “Your husband only has mild Alzheimer’s disease, so staying home alone is acceptable.” D. “There are organizations that may be able to provide an interim caretaker for your husband.” Copyright © 2021, Elsevier Inc. All Rights Reserved. Answer to Case Study Question 6 ANS: D The client has stage II (moderate) Alzheimer’s disease, based on his symptoms, and needs supervision. Providing information about organizations that may be able to help care for him is most appropriate. Asking the client’s wife to change her travel plans is nontherapeutic and does not address the underlying concern for the client’s safety. Copyright © 2021, Elsevier Inc. All Rights Reserved. Chapter 39 Audience Response System Questions Copyright © 2021, Elsevier Inc. All Rights Reserved. Question 1 The nurse notes that a client with Parkinson disease has resistance to passive movement of the lower extremities with mildly restrictive movement. Which documentation will the nurse use to describe this assessment finding? A. B. C. D. Plastic Rigidity Cogwheel Lead pipe Copyright © 2021, Elsevier Inc. All Rights Reserved. Answer to Question 1 ANS: A Assess the client for rigidity, or resistance to passive movement of the extremities, which is classified as: Cogwheel, manifested by a rhythmic interruption of the muscle movement Plastic, defined as mildly restrictive movement Lead pipe, or total resistance to movement Copyright © 2021, Elsevier Inc. All Rights Reserved. Question 2 When caring for a client with Parkinson disease, the nurse understands that progressive difficulty with which factor is a primary expected outcome? A. Nutrition B. Elimination C. Motor ability D. Effective communication Copyright © 2021, Elsevier Inc. All Rights Reserved. Answer to Question 2 ANS: C Parkinson disease is a progressive debilitating neurodegenerative disease affecting motor ability. As the disease progresses, the client may experience difficulty with communication, nutrition, ADLs, elimination, and cognition, yet motor ability is the primary function that is impacted. Copyright © 2021, Elsevier Inc. All Rights Reserved. Question 3 The family of a client with Alzheimer’s disease (AD) reports increasing symptoms of paranoia in the client. Which nursing response is appropriate? A. “There is often an underlying psychiatric condition with AD.” B. “Some clients with dementia may experience paranoia, delusions, and even hallucinations.” C. “This reflects a sign of rapid progression of the AD.” D. “Remind the client that their paranoia is unfounded.” Copyright © 2021, Elsevier Inc. All Rights Reserved. Answer to Question 3 ANS: B For some clients with dementia, emotional and behavioral problems occur; this does not mean that the client has a psychiatric disorder – it is a byproduct of the cognitive changes associated with AD. They may experience paranoia (suspicious behaviors), delusions, hallucinations, and depression. Document these behaviors, and ensure the client's safety. It will not benefit the client to remind them that the paranoia is unfounded, nor does it reflect a sign of rapid progression of AD. Copyright © 2021, Elsevier Inc. All Rights Reserved.
