The Nervous System - Part 1

Headaches Assessment

Pain, Quality, Radiation, Symptoms other than H/A, Time and Duration

Types of headaches

Migraine or Cluster

Migraines Pathophysiology

vascular or Neuronal hyperexcitability, family history

Migraines Vascular

Vasodilation, Irritation of trigeminal sensory fibers, Leads to further blood flow changes/severe H/A, Associated with cycling estrogen, Associated with serotonin levels

Migraines Neuronal hyperexcitability

Neurons with serotonin & norepinephrine activated

Migraines First seen in

child/teen years; 1 male: 3 females

Migraines May experience

cravings, light sensitivity, personality changes, fluid retention before H/A

Migraines Precipitants

fatigue, hunger, menses, stress, emotions

Aura

sings before Migraines

Migraines can occur with or without

aura

Migraines Avoid Triggers

Food Odors, Stress, Irregular sleep, exercise, meals, fluids

Migraines Avoid Triggers Food

Chocolate, Artificial sweeteners, Diet soda, Cured meats, Aged cheese, Nuts, Salty foods

Migraines Preventative drug Therapy

NSAIDS, Anticonvulsants, antihypertensives antidepressants

NSAIDs

Aspirin, Ibuprofen, Acetaminophen with caffeine

Anticonvulsants - headaches

Gabapentin (Nerontin), ↑ levels of neurotransmitters to ↓ pain impulses

Antihypertensives

Beta-adrenergic blockers (Propanolol) and Calcium-channel blockers amlodipine (Norvasc)

Beta-adrenergic blockers (Propanolol

Prevents vasoconstriction or rapid vasodilation in the cerebral blood vessels

Antidepressants

Citalopram (Celexa), Paroxetine (Paxil), escitalopram (Lexapro), or fluoxetine (Prozac)

Antidepressants MOA

↑ serotonin, dopamine, & norepinephrine in the brain

Antidepressants don’t take at the same time as

Mirgnage medications, serotonin syndrome (seizures, dysthymia, death)

Abortive Drug Therapy

Analgesics, triptan preps, Dihydroergotamines

Analgesics

ASA, Acetaminophen, Ibuprofen, Naproxen

Triptan Preps

Stimulates serotonin receptors; vasoconstrictive effect, Sumatriptan succinate (imitrex) SQ, PO, Nasal

Dihydroergotamines

Bind to the serotonin receptors on the nerve endings, ↓ the transmission of pain messages along the nerve fibers, Dihydroergotaimin (Migranal)

Migraines Nurse Management

Dark room, sleep, relaxation techniques, Quiet environment

Cluster headache

No family, genetic, dietary link, Age 20-50 yrs. at onset, Men to women ratio 6

Cluster headache more common with

ETOH, cigarette smokers, caffeine users

Cluster headache Pathophysiology

Irritation of trigeminal nerve, Vascular dilation

Cluster Headaches Pain

Remissions & exacerbations, Excruciating, unrelenting, non-throbbing, Unilateral in orbital/temporal or frontal area

Cluster Headaches Pain Occurs

at night or early morning

Cluster Headaches Duration

15-45 min q 8-12 hours; same time QD X 6-8 weeks; occurs in clusters 9-12 months apart (if drinking alcohol during this period cause more frequent HA)

Cluster Headaches May have

nasal congestion, droopy/watery eyes (could be permanent) ipsilateral

Cluster Headaches Management

Drug therapy, Avoid exposure to light & glare, Oxygen, Consistent sleep-wake cycle

Parkinson’s Disease

Loss of brain cells that produce dopamine, a chemical that helps direct muscle activity; loss of ability to refine movement

Parkinson’s Disease Etiology

Degeneration of substantia nigra , ACh transmits excitatory messages and there is not enough Dopamine to help balance those excitatory messages, Results in loss of fine motor movement

Parkinson’s Disease Risk factors

50,000/year, Men and women equally, Whites may have a higher incidence, Age usually > 50

Parkinson’s Disease Primary Symptoms

Resting tremors or trembling in hands (pill rolling), arms, legs, jaw & face , Muscle rigidity or stiffness of the limbs & trunk, Bradykinesia progressing to akinesia, Postural instability – shuffling gait, mask like facies

Akinesia

no movement

Parkinson’s Disease Other Frequent Symptoms

Some develop cognitive impairment and dementia, Mood alterations, Behavior alterations

Mask like facies starts in

stage 2, increase risk for aspiration, make sure meds are on time and before meals

Stage 1 of Parkinson’s Disease

Tremors occur on one side of the body, s/s don’t interfere with ADL

Stage 2 Parkinson’s Disease

Rigidity on both sides of the body, high risk of falls, walking and eating is more difficult, Aspiration risk, dry eyes,

Stage 3 Parkinson’s Disease

falls are common, help is needed to get arounds, shower, dress and eat,

Stage 4 Parkinson’s Disease

independent living is a challenge additional assistance for mobility and ADL is needed

Stage 5 Parkinson’s Disease

inability to stand, walk, eat or swallow, completely depended on car giver

Immobility risk

pneumonia (TCDB), pressure ulcers (turn), constipation (stool softeners), aspiration, blood clots, uti, infection

Parkinson’s Disease Diagnosis

No specific diagnostic tests, Clinical findings after other neurological diseases eliminated, CSF may show decreased dopamine

Parkinson’s Disease DRUG Management

Exact time schedule!, Drug combo, Carbidopa/levodopa (Sinemet), Catechol O-methyltransferase (COMT) inhibitors, Dopamine Receptor Agonists

Carbidopa/levodopa (Sinemet)

Levadopa ↑ production of dopamine, Carbidopa ↓ side effects of levodopa, Anticholinergics extend effects of levodopa therapy benztropine (Cogentin)

Carbidopa/levodopa (Sinemet) Must

administer 1 hour before or 2 hours after a meal, keep adequate protein intake

Catechol O-methyltransferase (COMT) inhibitors

COMT is an enzyme that inactivates dopamine. Entacapone (Comtan), opicapone (Ongentys)

Dopamine Receptor Agonists

Pramipexole (Mirapex), ropinirole (Requip), Makes Dopamine receptors more likely to respond to what Dopamine is there

Dopamine Receptor Agonists Side effects

include N/V, drowsiness, orthostatic hypotension, & disorders of impulse (gambling, hypersexuality)

Parkinson’s Disease Surgical Management

Stereotactic Pallidotomy, Deep Brain Stimulation, Fetal Tissue Transplantation

Stereotactic Pallidotomy

Target area is identified via CT and/or MRI, Burr hole made in cranium & electrode inserted to target area, Once the target area has been located, a permanent lesion is made to decrease tremor activity

Deep Brain Stimulation

Electrode implanted in thalamus & connect to a “pacemaker” in the upper chest that delivers electrical current to interfere with “tremor” cells

Fetal Tissue Transplantation

Experimental - highly controversial

Parkinson’s Management

Administer drugs ON TIME, Exercise/ambulation, Nutrition, Fall risk, Have suction equipment at bedside (aspiration), Stool softeners

Parkinson’s Exercise/ambulation

AROM, PROM, muscle stretching, swallowing & breathing exercise

Parkinson’s Nutrition

Administer medications before meals so that they can start working, Assess gag & swallowing, Elevate HOB while eating, ↑ fluids

Huntington’s Disease

Inherited, 50% chance of disease if 1 parent has disease, Autosomal dominant, 3rd/4th decade

Huntington’s Disease Dx

Family history & assessment

Huntington’s Disease Motor

Chorea, athetosis, Too little (rigidity or muscle stiffness) Dystonia, Bradykinesia

Chorea

involuntary random, uncoordinated movements, jerking

Athetosis

twisting, writhing, sometimes violent movements

Huntington’s Disease Mood

Depression common, Anxiety, OCD, irritability, temper outbursts, suicidal

Huntington’s Disease Cognition

Altered thinking, learning, & judgment, ↓ attention span, Memory loss, Affected early worsens over time

Huntington’s Disease medical Management

Currently no drugs to treat the cause but can treat symptoms with – Antidepressants, Antipsychotics, New drug is being tested to reduce abnormal levels of the protein, Genetic counseling

Huntington’s Disease Multidisciplinary Team

Neurologist, Psychologist, PT, OT, Speech therapist

Huntington’s Disease Management

↑ HOB when eating – assess gag & swallowing, Have suction equipment available, Fall risk, Suicidal precautions

Huntington’s Disease stages

Each stage progresses within about five years, Patients typically survive until after the third stage, takes 10-15 years, third stage bed written

Back Pain

Acute pain due to hyperflexion or twisting when lifting something or from MVA

Back Pain May be due to

obesity, smoking, scoliosis, poor posture, high-heeled shoes, poor sleeping positions, occupational risks, stress, depression

Back Pain Other causes

muscle strain/spasm, ligament, sprains, herniated nucleus pulposis

Herniated Disc

occurs when the soft, jelly-like center of a spinal disc breaks through its tough outer layer, usually in the lower back (lumbar) or neck (cervical).

Spinal Stenosis

the narrowing of the spinal canal, which compresses the spinal cord and nerves, May be due to spinal stenosis from disc degeneration

Mechanical Type Back Pain

Starts near lower spine, radiates, Pain on coughing, sneezing, straining, Weakness--leg, bladder, bowel (constipation)

Compressive or Neurogenic Back Pain

Nerve root is irritated or pinched, Swelling in back, Paresthesia, numbness, Severe pain on straight leg raising, Can’t bend, Limp abnormal gait, Abnormal posture, Constipation

Back pain diagonsistics

MRI, CT SCAN, MYELOGRAM, DISCOGRAM, EMG, NERVE CONDUCTION STUDIES

MYELOGRAM

imaging test—often followed by a CT scan—that uses contrast dye injected into the spinal canal

Other causes of back pain

Ulcers, kidney problems, aortic aneurysm

Management of Back pain

Prevention, Rest, exercise, & Physical Therapy - begin when acute pain gone, TENS unit, Ultrasound, Corset or back belt, Massage

Management of Back pain Tempurture

Moist heat, Hot showers, baths, Ice, Alternate ice and heat

Management of Back pain positioning

Roll pillow behind small of back, Sleep on side with pillow between knees,

Back pain medications

Muscle relaxants, NSAIDS, Opioids, Antidepressants, corticosteroids

Back pain Corticosteroids

PO, Local injection, Epidural injection

Surgical management of back pain

Discectomy, Laminectomy, Spinal fusion

Surgical management of back pain pre op

Bracing needed 3-6 months post-op if spine fusion done, Bone grafting needed

Surgical management of back pain Post-op Care

VS, Neuro Assessment q 4 hours, Pain control, Check drains and dressings, Numbness, tingling post-op

Surgical management of back pain Check for CSF

call doctor immediately if leaking, halo dressing, positive glucose, HA (give fluids)

Surgical management of back pain Check ability to void

if hour past without the feeling to void do bladder scan

Surgical management of back pain moving

Out of bed evening of surgery unless fusion done, Logroll q 2 hours if spine fusion (24 hr total), Deep breathe q 2 hours, Sequential compression devices

Surgical management Home care

3-6 months