Determine safe patient-centered nursing care using evidence-based practice for patients experiencing common sensory, perception, and cognition problems.
Identify development principles, prevention, and/or early detection of health problems and strategies in order to achieve the optimal health for adult and older adult patient experiencing common sensory, perception, and cognition problems.
Differentiate medications prescribed for patients experiencing common sensory, perception, and cognition problems.
Examine caring and professional behaviors required when providing nursing care for patients experiencing common sensory, perception, and cognition problems.
Examine effective verbal, nonverbal, written, and electronic communication required for the care of patients experiencing common sensory, perception, and cognition problems.
Use established practice standards and guidelines to ensure quality outcomes for patients experiencing common sensory, perception, and cognition problems.
Determine collaborative relationship needed to provide and improve care for patients experiencing common sensory, perception, and cognition problems.
Determine leadership skills required to provide care for patients experiencing common sensory, perception, and cognition problems.
SEIZURES (Ch 36)
Abnormal, uncontrolled, sudden, excessive discharge of neurons within the brain.
Results in a range of manifestations from behavior changes to loss of consciousness
Epidemiology:
No conclusive pathophysiological explanation
Genetic or developmental mutation of synapses
Ineffective activity of gamma-aminobutyric acid (GABA)
Nonepileptic Seizures: provoked by other disorders and conditions; referred to as secondary seizures
Pathophysiology
Clinical manifestations:
Rhythmic jerkiness of all extremities and loss of consciousness
Episodes of daydreaming and no loss of consciousness
Management:
Diagnosis of seizures: Imaging, laboratory work-up, and diagnostics via EEG monitoring
Medications in the treatment of seizures
Clinical Manifestations:
Unilateral, rhythmic muscle movements, automatisms (repetitive unconscious movements such as lip smacking, chewing, or swallowing), sudden loss of motor tone, and incontinence.
Preictal phase (just prior to the seizure): some will have an Aura with (pleasant or unpleasant odors, visualizations/hallucinations, the sense of “butterflies” in the stomach, a sense of déjà vu or the intense feeling that a seizure is about to happen).
Postictal phase: a period of 5 to 30 minutes after the seizure and is an altered state of consciousness. During this phase, the client can experience drowsiness, confusion, disorientation, nausea, hypoxia, headache, and migraine.
Management of Seizures
Labs, CT, and MRI can rule out causes such as lesions, tumors, metabolic, and other disorders.
Seizures can be difficult to diagnose in the elderly because of their resemblance to other conditions of old age such as dementia and Alzheimer’s disease.
Antiepileptic drugs (AEDs) or anticonvulsants almost always provide complete control of the seizures.
Reference tables and boxes in the textbook:
Read Table 36.2 page 904, 11th ed.
Action Alert p. 905
Best Practice Box p. 865
Critical Rescue and Drug Alert Boxes p. 906
Box 36.10 Health teaching for the patient with Epilepsy
Drug Therapy (Table 36.2)
Hydantoins:
Phenytoin
Fosphenytoin
Side effects include headache and drowsiness.
Perform frequent oral care and regular dental exams, if possible, due to gingival hyperplasia.
Patients should not be prescribed Phenytoin with warfarin drugs to prevent excessive bleeding and phenytoin toxicity.
When given IV for status epilepticus, dilute in 0.9% normal saline (NS).
Iminostilbenes:
Carbamazepine
Eslicarbazepine
Oxcarbazepine
Side effects: dizziness and drowsiness.
Monitor for a rash in patients starting carbamazepine.
Be aware that carbamazepine is also used for chronic neuropathic pain.
Succinimides:
Ethosuximide
Teach patients that drug may cause dizziness, drowsiness, impaired cognition, ataxia, and gingival hyperplasia.
Benzodiazepines:
Lorazepam
Clorazepate
Recognize that lorazepam is most often given intravenously to manage status epilepticus.
Be aware that clorazepate is used to prevent patient seizures; monitor for multiple side/adverse effects including hypotension and respiratory depression.
Miscellaneous:
Gabapentin
Lamotrigine
Topiramate
Pregabalin
Valproic acid
Ezogabine
Teach patients that any of these drugs can cause drowsiness and dizziness, especially when first starting them.
Recognize that some of these drugs can also be used to manage neuropathic pain, especially gabapentin and pregabalin.
Remind patients that topiramate can cause weight loss.
Drug Therapy: Patient teaching on Antiepileptic drugs (AEDs)
Follow up on laboratory tests to monitor CBC and liver enzymes and assess for therapeutic drug levels.
Most AEDs can cause leukopenia (low WBCs) and liver dysfunction.
Observe for and report beginning gingival hyperplasia and perform frequent oral care to prevent permanent gingival damage.
AED’s can cause osteoporosis in menopausal women.
Take their drugs on time to maintain therapeutic blood levels and maximum effectiveness.
Check serum drug levels as they decrease with use.
Never stop this drug abruptly even if you have side effects without discussing it with the provider.
Clinical Manifestations: Generalized Seizures
Absence Seizures (Petit Mal)
Myoclonic Seizures
Atonic Seizures (drop attacks)
Grand Mal/Tonic-clonic
Lasts 2 to 5 minutes
Jerking motions
Loss of consciousness
May bite tongue
Incontinence
Staring
Body movements
Loss of consciousness
Sudden jerks or twitches of the arms and legs
Loss of normal muscle
Sudden collapse
Loss of consciousness
Body stiffening
Shaking
Types of Seizures
Generalized seizure: lasts 2 to 5 minutes, present with jerking motions (stiffening then relaxing), loss of consciousness, may bite tongue, incontinence of bowel and/or bladder; postictal the patient will exhibit fatigue, confusion, and lethargy for approximately one hour.
Absence seizures: also called petit mal, involve the patient initially staring and then subtle body movements develop. A brief loss of consciousness can occur with absence seizures.
Myoclonic seizures: involve sudden jerks or twitches of the arms and legs.
Atonic seizures: also known as drop attacks, result in a loss of normal muscle tone and in sudden collapse. The patient may fall down.
Tonic-clonic seizures: also called grand mal. These are the most intense of all types of seizures. With tonic-clonic seizures, the patient has a loss of consciousness, body stiffening, and shaking.
Nursing Safety: Seizure precautions include
Ensuring that oxygen and suctioning equipment with an airway are readily available.
If the patient does not have an IV access, insert a saline lock, especially if he or she is at significant risk for generalized tonic-clonic seizures.
The saline lock provides ready access if IV drug therapy must be given to stop the seizure.
Patient can become cyanotic during a generalized tonic-clonic seizure.
High-risk patients such as the elderly or critically ill can be given oxygen via nasal cannula or face mask during the Postictal phase.
Care of Patient during a Tonic-Clonic or complex Partial Seizure (Box 36.9 page 905)
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.
Care of Patient during a Tonic-Clonic or complex Partial Seizure (Box 36.9 page 905)
At the completion of the seizure:
Take the patient’s vital signs.
Perform neurologic checks.
Keep the patient on his or her side.
Allow the patient to rest.
Document the seizure:
How often the seizures occur: date, time, and duration of the seizure
Whether more than one type of seizure occurs
SEIZURES: Complications
Status Epilepticus
Seizure greater than 5 minutes is a medical emergency
Seizures greater than 30 minutes can cause respiratory failure, brain damage, and death
Surgical Management
Vagal nerve stimulator (VNS), deep brain stimulation, and partial corpus callosotomy
Complications of Seizures
Status epilepticus: seizure activity lasting greater than 5 minutes or two or more seizures without full recovery of consciousness can be caused by head trauma, hydrocephalus, acute drug or alcohol withdrawal, metabolic disturbances, or abrupt withdrawal of anticonvulsive medications.
ABC (airway, breathing, circulation) intervention needs to be initiated immediately. Intubation to protect the airway needs to be considered and initiated if appropriate.
Lorazepam (Ativan) and Midazolam (Versed) are first-line drugs in the immediate treatment of seizures and status epilepticus. Both are Benzodiazepines.
To stabilize the patient, a loading dose of Phenytoin (Dilantin) or Levetiracetam (Keppra), both anticonvulsants, is generally administered along with continuous dosing.
If the instances of the seizure are refractory to all interventions, clients are placed on high doses of Propofol (Diprivan) or placed in a Pentobarbital coma.
Continuous EEG monitoring for burst suppression is initiated.
Surgical Management of Seizures
Similar to a cardiac pacemaker, the vagal nerve stimulator (VNS) can provide relief for those suffering from refractory simple or complex seizures.
Patient can activate the VNS when experiencing an aura, thus aborting a seizure.
Deep brain stimulation involves implanting electrodes into the brain that release electrical impulses.
Another approach is the partial corpus callosotomy.
A craniotomy is performed, and the connection between the right and left hemispheres of the brain is either disrupted partially or totally severed.
PARKINSON'S DISEASE (Chapter 36 - 11th edition)
Epidemiology
1.5x to 2x more common in males than in females
Begins between ages of 40-70 years
Pathophysiology
Progressive, neurodegenerative disease of the CNS
Manifesting primarily in motor dysfunction
Primarily of idiopathic origin
Loss of dopamine-producing brain cells in the substantia nigra of the basal ganglia, culminating in a decreased amount of dopamine in the brain.
Parkinson's disease (PD) is a slow progressive disorder of the nervous system that affects movement and results in crippling disability.
PARKINSON'S DISEASE
The diagnosis of Parkinson's disease (PD) can be difficult.
It is recommended that all people suspected of having PD be referred to a neurologist for diagnosis and initial planning of care.
The manifestations do not appear until about 60% of the normal amount of dopamine is lost.
Stages of Parkinson’s Disease:
Stage 1: Initial Stage
Unilateral limb involvement
Minimal weakness
Hand and arm trembling
Stage 2: Mild Stage
Bilateral limb involvement
Masklike face
Slow, shuffling gait
Stage 3: Moderate Disease
Postural instability
Increased gait disturbances
Stage 4: Severe Disability
Akinesia
Rigidity
Stage 5:
Complete ADL Dependence (BOX 36.6)
Clinical Manifestations of Parkinson's Disease
Tremor
Muscle rigidity
Increased tone and stiffness in muscles at rest
Freezing movement
Bradykinesia or akinesia
Flexed posture
Loss of postural reflexes
Six Cardinal features of Parkinson's Disease
Tremor at rest on one side - the first manifestation in 70% of patients
Rigidity, Increased tone, and stiffness in muscles at rest (pill rolling)
Bradykinesia – (slow movement) - fine motor movements that become clumsy and make voluntary movements difficult to execute.
Bradykinesia also affects gait. Initially there may be a slight stiffness of one leg while walking, and the ipsilateral arm may be held flexed at the elbow and abducted at the shoulder. The person may catch or drag one foot.
Later, when both sides of the body are involved, the typical shuffling gait with short steps may develop. There is a lack of associated swinging of the arms while walking.
In advanced PD, the patient stands with head, shoulders, and spine flexed forward, giving the appearance of a stooped posture.
Akinesia – no movement
Flexed posture of the neck, trunk, and limbs
Loss of postural reflexes
Freezing movement - with freezing movement, the patient will eventually appear stiff, mask-like, and without expression. Speech will become slow, monotone, and low in volume, as well as monotonous in tone.
Nursing Care and Evidence Based Practice for Parkinson's Disease
Drug Therapy
Physical Therapy
Rehabilitation
Nursing Care for Parkinson's Disease
Nursing Interventions
Talk with and listen to patient and family concerns.
Explain the prescribed medication regime and the side effects of medications.
Explain all procedure and care in terms that the patient and family will understand
They must know when to contact the PCP.
Complete thorough physical and neurological assessment, including vital signs!
Instruct the patient in postural exercises and walking techniques to offset shuffling gait and the tendency to lean forward. Marching to music can help with this.
Encourage the patient not to hurry to complete speech. Refrain from completing sentences for the patient.
Monitor for drug side effects, especially orthostatic hypotension, hallucinations, and acute confusional state (delirium).
Place the patient on Fall Precautions.
Assess for depression, anxiety, and impaired cognition. Assess for insomnia or sleeplessness.
Drug Therapy
Emphasize the importance of a daily exercise program.
Encourage participation in therapy and in social and recreational events to prevent withdrawal and depression.
Collaborate with physical and occupational therapists to keep the patient as mobile and independent as possible in ADLs.
Encourage nontraditional exercise programs such as yoga and Tai chi to improve mobility in early stages of disease.
Allow the patient time to perform ADLs and mobility skills; provide assistance only if needed.
Implement interventions to prevent complications of impaired mobility, such as constipation, pressure injuries, and contractures. Encourage high-fiber diet.
Physical Therapy
Consult with speech therapy to practice speech exercises.
Encourage participation in physical therapy and an exercise program to improve coordination and dexterity.
Schedule appointments and activities late in the morning to prevent rushing the patient, or schedule them at the time of the patient’s optimal level of functioning.
Teach the patient to speak slowly and clearly. Use alternative communication methods, such as a communication board or handheld mobile device.
Refer to the speech-language pathologist.
Monitor the patient’s ability to eat and swallow. Monitor actual food and fluid intake. Collaborate with the registered dietitian nutritionist to provide high-protein, high-calorie foods or supplements to maintain weight.
Therapeutic Management for Parkinson's Disease
Levodopa
Carbidopa
Anti-cholinergic
Antivirals
Dopamine agonists
Drug Therapy for Parkinson's Disease
The most effective therapy for Parkinson's disease is levodopa, which is converted to dopamine in the brain.
There are unpleasant side effects- shortened response to each dose, painful cramps, and involuntary movements.
Levodopa is frequently prescribed together with Carbidopa as Sinemet or Atamet, which prevents levodopa from being broken down before it reaches the brain.
Carbidopa allows for a lower levodopa dose, thereby reducing side effects.
Anticholinergics and antivirals may also be prescribed.
Dopamine Agonists such as Mirapex (Pramipexole), Requip (Ropinerole), or Parlodel (Bromocriptine) may be prescribed.
These drugs do not convert to dopamine in the brain as Levodopa does, but instead mimic the effect of dopamine on the brain.
Dopamine agonists are not as effective as Levodopa/Carbidopa for the treatment of motor symptoms.
They may also cause other side effects including daytime sleepiness, sudden unanticipated sleep ("sleep attacks"), hallucinations, and risk-taking behavior-such as gambling and sexual obsessions.
For some patients with advanced, virtually unmanageable motor symptoms, surgery may be an option.
In deep brain stimulation (DBS), the surgeon implants electrodes deep within the parts of the brain that control movement.
The amount of stimulation delivered by the electrode is controlled by a pacemaker-like device placed under the skin in the chest.
MAO inhibitors
Catechol-O-methyltransferase inhibitors- they inactivate dopamine.
Antidepressants
Antihistamines
Patient Teaching for Parkinson's Disease
Patients should be encouraged to take warm baths and showers to help relax muscles and relieve spasms.
Inform the patient about the American Parkinson's Disease Foundation
Instruct the patient to consume a well-balanced diet and establish a regular bowel routine with high fiber and plenty of fluids.
Nutritional problems may develop from difficulty with chewing and swallowing, from medications.
Care of the Patient With Parkinson Disease (Box 36.7 11th ed.)
Allow the patient extra time to respond to questions.
Administer medications promptly on schedule to maintain continuous therapeutic drug levels.
Provide drug therapy for pain and/or tingling in limbs.
Monitor for drug side effects, especially orthostatic hypotension, hallucinations, and acute confusional state (delirium).
Place the patient on Fall Precautions.
Collaborate with physical and occupational therapists to keep the patient as mobile and independent as possible in ADLs.
Encourage nontraditional exercise programs such as yoga and Tai chi to improve mobility in early stages of disease.
Allow the patient time to perform ADLs and mobility skills; provide assistance only if needed.
Implement interventions to prevent complications of impaired mobility, such as constipation, pressure injuries, and contractures. Encourage high fiber diet.
Schedule appointments and activities late in the morning to prevent rushing the patient, or schedule them at the time of the patient’s optimal level of functioning.
Teach the patient to speak slowly and clearly. Use alternative communication methods, such as a communication board or handheld mobile device. Refer to the speech-language pathologist.
Monitor the patient’s ability to eat and swallow. Monitor actual food and fluid intake. Collaborate with the registered dietitian nutritionist to provide high-protein, high-calorie foods or supplements to maintain weight.
Assess for depression, anxiety, and impaired cognition. Assess for insomnia or sleeplessness.
Multiple Sclerosis
NUR 242 Unit 10
Chapter 37 11th ed.
MULTIPLE SCLEROSIS
Epidemiology
Autoimmune disease
400,000 people have MS with onset between 20-50 yrs
Affects more women than men
4 main types:
Relapsing-remitting
Secondary progressive
Progressive relapsing
Primary progressive
MULTIPLE SCLEROSIS
Pathophysiology
Immune system attacks the brain and spinal cord
Chronic neurological disorder
Clinical manifestations
Numbness or weakness in limbs, partial or complete vision loss, tingling or pain, electric-shock sensations with head movements, tremor, lack of coordination, or unsteady gait, fatigue, and dizziness.
Read Box 37.1 pg 916 11th ed.
Types of Multiple Sclerosis
Relapsing Remitting (RRMS)
Symptoms flare up, followed by periods of stability between attacks
Most common type of MS
Primary Progressive (PPMS)
Gradual continuous deterioration from the onset of the disease
Secondary Progressive (SPMS)
RRMS progresses to gradual neurological deterioration
Remissions may not occur
Progressive Relapsing (PRMS)
Gradual continuous neurological deterioration with acute flare-ups
Risk Factors for Multiple Sclerosis
Infection
Physical injury
Emotional stress
Pregnancy
Fatigue
Living in cold climates
Multiple Sclerosis: Management
No specific test; can be difficult to diagnose
History, physical, and neurological examination
No cure
Treatment
Improving the speed of recovery from attacks
Reducing the number of attacks
Slowing the progression of the disease
Medications used to treat clinical manifestations
Therapeutic Management for Multiple Sclerosis
Corticosteroids
Interferons
Methotrexate Plasmapheresis
Intravenous
Anticholinergic
Immune
Cholinergics
Globulin
Nursing Care and Evidence-Based Practice for Multiple Sclerosis
Assess:
Medical history
Mobility impairment
Sexual, bladder, and bowel dysfunction
Swallowing impairment
Skin integrity
Provide:
Emotional support
Physical therapy
Occupational therapy
Speech therapy
Mental health services
Multiple Sclerosis: Common complications
Muscle stiffness or spasms
Paralysis, often in the legs
Problems with bladder, bowel, or sexual function
Mental status changes — memory loss, problems concentrating
Depression
Seizures
Cultural and Age Considerations for Multiple Sclerosis
More prominent in the colder climates
Affects twice as many women than men
More prominent in the white population
People between the ages of 20 and 40 years are at a greater risk
Patient Teaching for Multiple Sclerosis
Follow medication regimen
Minimize exacerbations
Increase fluids and fiber
Adhere to interdisciplinary team regimens
Wear eye patch for diplopia
Follow safety precautions
Prevent skin breakdown
Restless Leg Syndrome (RLS)
NIH Fact Sheet on Restless Leg Syndrome
Restless Leg Syndrome or Willis-Ekbom Disease is a neurological disease that causes a client's legs to have unpleasant or painful sensations when they are stationary for long periods of time and/or in the later afternoon or evening period, becoming most severe at night when the client is trying to go to sleep.
Clients report that walking helps relieve symptoms, however as these occur close to bedtime, this is not the ideal time to move around.
RLS can occur at any age and affects both men and women, though women are more likely to have RLS.
Causes and Risk Factors for Restless Leg Syndrome
There are many factors that can cause and worsen the symptoms of Restless Leg Syndrome.
Pregnancy
Genetics
Chronic Diseases
Deficiencies
Medications
Caffeine & Alcohol
Restless Leg Syndrome: Signs & Symptoms and Causes
Signs & Symptoms of RLS
Unable to concentrate, impaired memory, poor sleep, fail to accomplish daily tasks, daytime sleepiness, relationships, school or work performance, or mood.
Nursing Care and Evidence-Based Practice for Restless Leg Syndrome
Patients are not hospitalized for RLS but may be hospitalized for other disorders.
Refer to the Restless legs Foundation
Instruct patient on relief measures
Monitor lab values
Explain all procedures and care in terms that the patient will understand
Restless Leg Syndrome: Key Points
Restless Legs Syndrome is seen in approximately 10% of the American population, more in women than men
Sleep deprivation is a major concern
Medications can relieve symptoms but may require time to find a successful combination for relief
Teaching is needed for medication regimen and avoiding contributing factors