Chapter 39
Care of Patients with Problems of the
Central Nervous System: The Brain
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Concepts
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The priority concepts in this chapter are
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Cognition
Mobility
The interrelated concept in this chapter is
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Pain
Infection
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Alzheimer’s Disease
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Pathophysiology Overview
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Most common type of dementia
Microscopic changes of the brain – neurofibrillary
tangles, neuritic plaques, beta amyloid
Neurotransmitter abnormalities
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Alzheimer’s Disease:
Etiology and Genetic Risk
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Age
Gender
Genetics
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Alzheimer’s Disease:
Incidence and Prevalence
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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)
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Alzheimer’s Disease:
Health Promotion and Maintenance
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No proven way to prevent AD
Chronic health problems may contribute
Diet
Exercise
Stop smoking and drinking
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Alzheimer’s Disease:
Assessment: Recognize Cues (1 of 2)
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History
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Physical assessment
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Onset, duration, progression, course of symptoms
Functional status
Stages
Attention, concentration, judgment, perception,
learning memory, communication and language,
information processing
Psychosocial assessment
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Alzheimer’s Disease:
Assessment: Recognize Cues (2 of 2)
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Laboratory and imaging assessment
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Brain tissue examination at autopsy is only definitive
diagnosis
 Genetic testing
 CT
 MRI
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Alzheimer’s Disease: Analysis:
Analyze Cues & Prioritize Hypotheses
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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
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Alzheimer’s Disease:
Planning and Implementation:
Generate Solutions and Take Action
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Managing memory and cognitive dysfunction
Preventing injuries or falls
Preventing elder abuse
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Alzheimer’s Disease: Care Coordination
and Transition Management
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Home care management
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Self-management education
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Respite care
Preparation in case patient becomes agitated
Teach family about drug therapy
Maintain mobility as long as possible
Health care resources
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Alzheimer’s Association
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Alzheimer’s Disease:
Evaluation: Evaluate Outcomes
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Maintain memory and cognition for as long as
possible and increase quality of life
Remain injury-free
Manage caregiver stress to prevent elder abuse
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Mobility Concept Exemplar:
Parkinson Disease (PD)
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Pathophysiology Overview
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Progressive neurodegenerative disorder
Four cardinal symptoms
• Tremor
• Muscle rigidity
• Bradykinesia
• Postural instability
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Parkinson Disease:
Etiology and Genetic Risk
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Environmental and genetic factors
Exposure to chemicals and metals
Older than 40 years old
Familial tendency
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Parkinson Disease:
Incidence and Prevalence
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60,000 new cases annually in people over 50
years old
1 million live with PD
50% more men than women
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Parkinson Disease:
Assessment: Noticing
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History
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Physical assessment
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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
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No specific diagnostic tests
May do CSF, MRI, or SPECT
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Parkinson Disease
The image to the right
portrays the masklike
facial expression typical
of clients with Parkinson
disease.
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Parkinson Disease: Analysis:
Analyze Cues & Prioritize Hypotheses
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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
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Parkinson Disease: Planning and
Implementation: Responding
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Promoting mobility
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Nonsurgical management
Surgical management
Managing cognitive dysfunction
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Parkinson Disease: Care Coordination
and Transition Management
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Home care preparation
Self-management education
Health care resources
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Parkinson Disease:
Evaluation: Evaluate Outcomes
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Improve mobility to provide self-care and not
experience complications of impaired mobility
Maintain safety and an acceptable quality of life
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Migraine Headache
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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
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Abortive therapy
APAP or NSAIDs
Triptan preparations, ergotamine derivatives,
isometheptene combinations
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Seizures and Epilepsy
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Seizure
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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
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Chronic disorder in which repeated unprovoked
seizure activity occurs
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Types of Seizures
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Tonic-clonic
Myoclonic
Atonic (akinetic)
Partial (focal or local)
Complex partial (psychomotor or temporal lobe)
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Seizures and Epilepsy:
Etiology and Genetic Risk
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Primary
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Genetics
Secondary
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Underlying brain lesion (tumor or trauma)
Metabolic disorders
Acute alcohol withdrawal
Electrolyte disturbances
High fever
Stroke
Head injury
Substance abuse
Heart disease
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Seizures and Epilepsy:
Interprofessional Collaborative Care
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Assessment: Recognize Cues
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Number, timing, pattern of seizures
Preictal phase
Other medical history
EEG, CT, MRI, SPECT/PET
Interventions: Take Action
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Nonsurgical management
Surgical management
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Seizure Management
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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.
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Acute Seizure and
Status Epilepticus Management
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Medical emergency
IV-push lorazepam or diazepam, or diazepam
rectal gel
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Seizures and Epilepsy:
Care Coordination and Transition
Management
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Compliance with AEDs
Social services referral
Balanced diet and rest, stress-reduction
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Meningitis
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Pathophysiology Overview
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Infection of the meninges of the brain and spinal
cord, specifically the pia mater and arachnoid
 Types
• Viral (aseptic)
• Bacterial
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Meningitis:
Interprofessional Collaborative Care
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Assessment: Recognize Cues
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Neurologic and neurovascular assessment
Nuchal rigidity
Increased ICP
Interventions: Take Action
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Vaccination for prevention
 Accurate monitoring and documentation of
neurologic status
 Broad-spectrum antibiotics
 Vascular assessment
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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.”
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Answer to Case Study
Question 1
ANS: B
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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.
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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.
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Answer to Case Study
Question 2
ANS: D
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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.
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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
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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.
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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
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Answer to Case Study
Question 4
ANS: A
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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.
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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.”
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Answer to Case Study
Question 5
ANS: A, B, C
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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.
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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.”
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Answer to Case Study
Question 6
ANS: D
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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.
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Chapter 39
Audience Response System Questions
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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
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Answer to Question 1
ANS: A
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Assess the client for rigidity, or resistance to
passive movement of the extremities, which is
classified as:
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Cogwheel, manifested by a rhythmic interruption of
the muscle movement
Plastic, defined as mildly restrictive movement
Lead pipe, or total resistance to movement
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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
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Answer to Question 2
ANS: C
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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.
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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.”
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Answer to Question 3
ANS: B
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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.
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