Week 2 Chronic Neurological Flashcards
This week you will learn about chronic neurological conditions including the impact and management of these. These include: Parkinson’s disease, Epilepsy, Multiple Sclerosis, Headaches, Motor Neuron Disease, Guillian-Barre Syndrome, Huntington’s disease. We also delve into preparing and administering IV medications
Parkinson’s Disease (PD) is
a chronic progressive neurodegenerative disorder which involves the death of dopamine-releasing neurons and/or the formation of ‘Lewy bodies’ which are small spherical protein deposits that are found in neurons.
Whilst there is no definitive cause for a person to develop PD, we do know that
when the nerve cells within the brain that are responsible for producing dopamine become damaged or die, symptoms progressively develop
Research has shown that causes are often a blend of different factors, both known and unknown. Some risk factors can include the following:
Age - the biggest risk factors is advancing age with the average age of onset being over 60’s. That being said research is showing that people of a younger age can be just at risk as those over 60.
Gender - Research has shown that men susceptible to develop PD than women, with a ratio of approximately 3:2.
Genetics - those who have a parent or a sibling with PD, are twice as likely to develop PD. It has been shown, that families with certain groups of mutated genes can lead to PD, however it is not understood how these interactions between the mutated genes, and individual risk actually impact and increase the risk.
Environmental causes - exposure to chemicals, such as pesticides and herbicides, working with heavy metals, detergents and solvents have all been linked to cases.
Head trauma - whilst this is not a definitive cause, it is believed that repeated blows to the head is a likely risk of developing PD. It was determined as the cause for Muhammad Ali’s reason for developing PD later in life.
The symptoms of PD can be considered in three main areas:
Motor Symptoms
Non-Motor Symptoms
Neuropsychiatric Symptoms
Typical PD motor symptoms are __
often remembered as the acronym T.R.A.P:
Tremor
Rigidity
Akinesia
Postural Instability
Typical PD Non-Motor Symptoms
Bowel & Bladder Dysfunction
Orthostatic Hypotension
Temperature Imbalance
Sleep Disorders
Sexual Difficulties
Typical PD Neuropsychiatric Symptoms
Bradyphernia
Depression & Anxiety
Hallucinations, Psychosis & Dementia
Diagnosis of PD
There is not specific diagnostic tool to identify PD and will predominatly rely on robust assessments and reporting of symptoms.
Tests that may be conducted include:
MRI brain
Dopamine transporter chemical scan
Metaiodobenzylguanidine (MIBG) scan of the heart
Lumbar puncture
Nursing Management of Parkinson’s Disease
assessing and ideniftying symptoms and responses to the medications prescribed. Therefore when performing assessments it is important to include in our assessments the symptoms that accompany PD. Asking questions around the intensity, frequency and duration of symptoms is vital. Another important assessment to conduct in conjunction with the above is for the patient to be able to convey the level of distress the associated symptoms cause them and the impact of those symptoms.
Epilepsy is
a chronic neurological disorder that is characterised by recurrent seizures caused by a temporary dirsuption of the brain’s electrical activity. Epilepsy is the fourth most common neurological disorder after migraine, stroke and Alzheimer’s disease.
Epilepsy can be classified into two different categories.
- Idiopathic (no identifiable cause).
- Secondary to conditions affecting the brain or other organs.
Epilepsy Risk Factors
- 60% unknown cause
- Genetics
Brain abnormalities that occur in utero
Low oxygen during birth
Brain injury, such as after a traumatic head injury
Brain infection, such as meningitis or encephalitis
Stroke, which can lead to scarring of the brain
Brain tumour, either benign or melignant
Neurodegenerative dieases, such as Alzheimer’s disease
Drug and alcohol abuse
Cerebral palsy
Epilepsy by age
Seizures Types and Classifications
Seizures are divided into 3 major groups:
Focal Onset
Generalised Onset
Unknown Onset
focal seizure characteristics
Can be subtle and may go unnoticed
About 60% of epilitics have focal onset seizures
Often confused with the patient being intoxicated or simply day dreaming
Focal seizures can be further divided into 2 groups depending on a person’s awareness during the seizure activity
Focal aware
Person is fully aware, but often cannot communicate.
These are usually brief and can often be a warning sign (aura) that a more significant seizure may develop.
Aura’s can include - smell or taste sensations, butterflies, nausea
Focal impaired awareness
Your patient may appear confused, vague or disorientated as their awareness is impacted.
The patient may do repetitive actions or strange actions.
Repetitive actions can include - fiddling with clothing, making chewing movements, lip smacking, uttering unusual sounds
Generalised motor seizure
May involve stiffening (tonic) and jerking (clonic), known as a tonic-clonic seizure.
Your patient may produce excessive saliva, go blue in the face, experience incontinence, or bite their tongue or cheek.
Generally last from 1 to 3 minutes, if lasts longer than 5 minutes is classed as a medical emergency.
The patient will be post-ictal and feel sleepy, confused or tired.
Generalised non-motor seizure
Your patient may have brief changes in awareness, staring, and have come automatic or repeated movements.
Broken down into a further classifications based on the symptoms
Absent
Tonic - clonic
Myoclonic
Tonic
Atonic
Clonic
Absent seizure
- sudden lapse in awareness and activity. These are brief only typically lasting a few seconds.
Tonic - clonic seizure
- the body stiffens (the tonic phase) and then the limbs begin to jerk (the clonic phase.
Myoclonic seizure
- sudden single jerks of a muscle or group of muscles. Only lasts a few seconds.
Tonic seizure
- can occur when a person is asleep or awake and invloves brief stiffening of the body, arms or legs.
Atonic seizure
- brief seizures that cause a sudden muscle loss and the person often falls to the ground.
Clonic seizure
- although uncommon, they cause jerking in various parts of the body.
Unknown seizure
Unknown onset means the seizure cannot be diagnosed as either focal or generalised onset. Sometimes this classification is temporary and as more information becomes available over time or through further testing, the type of seizure may be changed to a generalised or focal onset seizure.
Signs and Symptoms
Depending on where the seizure originates will determine the signs and symptoms that will be seen in your patient.
Typical signs of seizure activity include:
temporary changes in mental status and LOC, your patient may appear confused or appear to be staring into space.
abnormal sensory changes
abnormal movements
psychological symptoms such as fear, anxiety or deja vu
There are several phases that a seizure may progress through:
Prodromal phase
Aural phase
Ictal phase
Postictal phase
Prodromal phase
- your patient may report signs that precede a seizure and lets them know a seizure is about to occur. This can happen hours or days before the seizure activity occurs. Some common signs include - mood changes, anxiety, difficulty sleeping.
Aural phase
- this stage is considered the early part of the seizure and your patient will experience sensory warnings such as; deja vu, odd smells, sounds or tastes, headache, panic.Sometimes a person may have an aura which doesn’t progress to become a more severe or prolonged seizure. Some people don’t experience an aura at all, and their seizure has no early warning signs.
Ictal phase
- the episode of the seizure. It’s the time from the first symptom to the end of the seizure activity. It is during this time that intense electrical activity is occurring in the brain. Some common signs of this phase include: loss of awareness, memory lapse, twitching, loss of muscle control, repeated movements.
Postictal phase
- the recovery period following the seizure. This is the recovery stage and during this phase any physical after effects of the seizure are felt. The type of seizure and the part of the brain involved will determine how long it takes for a person to return to their usual self. Your patient during this phase may be confused, tired, exhausted, embarrased, or have an injury.
Signs of seizure in frontal lobe
seizures that begin here may cause:
loss of motor control
change in behaviour
change in language expression
Signs of seizure in occipital lobe
seizures that begin here may cause a person to see:
multi-coloured shapes, such as circles and flashes
experience temporary loss of vision
Signs of seizure in parietal lobe
seizures that begin here may cause a person to feel:
numbness or tingling
burning or cold sensations
Signs of seizure in temporal lobe
seizures that begin here may cause a person to experience:
odd smell
odd taste
buzzing or ringing in the ears
fear or panic
deja vu
abdominal discomfort
Diagnostic Studies for epilepsy
- A Neurological Examination (behavior, motor abilities, mental function and other areas to diagnose the condition and determine the type of epilepsy)
- Blood Tests (signs of infections, genetic conditions or other conditions)
- Electroencephalogram (EEG)
- Computerised Tomography (CT) (abnormalities in the structure of the brain - tumors, bleeding and cysts)
- Magnetic Resonance Imaging (MRI) (detect lesions or abnormalities in your brain)
Electroencephalogram (EEG)
This is the most common test used to diagnose epilepsy. In this test, electrodes are attached to the scalp with a paste-like substance or cap. The electrodes record the electrical activity of the brain.
When a person has epilepsy, it’s common to have changes in the normal pattern of brain waves, even when they are not having a seizure.
High-density EEG. In a variation of an EEG test, the specialist may recommend high-density EEG, which spaces electrodes more closely than conventional EEG – about a half a centimeter apart. High-density EEG may help idenitfy more precisely which areas of the brain is affected by seizures.
Nursing Management of seizures
Nursing care must be person centered and holistic incorporating physical, psychological and social assessments. Nursing plays a crucial role in promoting optimal outcomes by providing education about the disease and self-management skills.
if status epilepticus occurs, which is defined as continued generalized convulsive or focal seizures lasting 5 or more minutes with no intervening recovery or consciousness. These are considered a medical emergency
Multiple sclerosis (MS) is
an autoimmune disease which attacks the central nervous system causing damage to the myelin sheath. When this is damaged this interferes with messages between the brain and other parts of the body
There are 4 main types of MS:
Relapsing-remitting - this is the most common form.
Primary progressive
Secondary Progressive
Progressive-relapsing
No one knows the exact cause of MS but it is thought that a mixutre of genetic and environmental factors are likely to play a role. The onset is usually
between 20 and 40 years of age peaking around the age of 25. MS is more common in women than men.
There are many symptoms that can be linked with MS and they can be variable and unpredicatable
Dizziness and Vertigo
Visual Disturbances
Cognitive dysfunction
Fatigue
Sexual Issues
Bladder and Bowel Issues
Tremor
Pain
There is no one specific diagnostic test for MS. The goal is to rule out other similar neurological conditions.The following diagnostic studies may be performed following a robust neurological examination.
MRI Scan
Lumbar puncture
CT Scan
Evoked potential test
Blood tests
What is an evoked potential test
An evoked potential test involves putting small electrodes on your head, arms or legs to measure the speed of messages travelling along your nerves from your eyes, ears or skin on your limbs. If the messages are slowed then this may be due to MS.
What is MRI
This scan can detect the scars used by MS which show up as little white patches and are usually called lesions. Everyone gets more white patches in their brain as they get older so the neurologist has to judge if they are all age-related or possibly due to MS.
Sometimes a dye is injected into the vein before the scan as it can help the radiologist and neurologist distinguish between active MS lesions and old areas of scarring.
What is Lumbar puncture
Lumbar punctures remove out a small amount of the fluid which bathes your brain and spinal cord (cerebrospinal fluid, or CSF). This is analysed in the laboratory to see if the fluid contains unusual antibodies, fragmented myelin nerve coating or an unusual amount of white blood cells. These findings might suggest MS or an alternative diagnosis.
What is CT
CT scans may be used to exclude other causes of neurologic impairment, but they have a low positive predictive value in the diagnosis of MS; thus, the false-negative rate is high. CT scans can help assess the degree of cerebral atrophy associated with advanced MS.
What is blood tests
Blood tests are used to rule out other causes for various neurological symptoms
Interprofessional Care
Because of the wide range of possible symptoms of MS, a number of different health professionals will be involved with the care of your patient. Who is involved will depend on how active the MS is, what symptoms the patient is experiencing, what treatments are available and the way that the local MS service works. Members of this team will work together to optimise outcomes and quality of life.
Medication Therapy used in MS
Nursing Management for MS
Nursing care must be person centered and holistic, incorporating physical, psychological and social assessments.
Psycho-social support is paramount for newly diagnosed patients and it is important to liaise with the interdisciplinary care team as soon as the patient has arrived on the ward.
Promote independence (Schedule the most strenuous activities in the morning);
Arrange for Chest physio via physio’s and encourage and help with ROM exercises;
Help to manage fatigue and identify contributing factors (Encourage the person to avoid temperature extremes eg: Showers.)
Swallow assessment (involve speech therapists);
Assess for urinary retention and teach interventions related to altered bladder and bowel function (bladder scan to ascertain if the need for IDC/self catheterisation; maintain 2L fluid daily, constipation management);
Monitor for signs of UTIs;
Psycho-social support;
Referrals to interdisciplinary team members.
Complications
Complications can develop inconjunction with MS. They can range from mild to severe and differ from person to person. Some of the complications can include:
Muscle Stiffness and Spasticity
Bowel and Bladder Problems
Vision Problems
Sensory Impairment
Mental Changes
Depression
Headaches are
one of the most common reasons for pain that someone experiences
Tension-type headache
Site
Quality
Frequency
Duration
Time and mode of onset
Associated Symptoms
Site
Bilateral, band-like pressure at base of skull
Quality
Constant, squeezing tightness
Frequency
Cycles for many years
Duration
30 minutes to 7 days
Time and mode of onset
Not related to time
Associated Symptoms
Palpable neck and shoulder muscle tension, stiff neck, tenderness
Migraine headache
Site
Quality
Frequency
Duration
Time and mode of onset
Associated Symptoms
Site
Unilateral, may switch sides, commonly anterior
Quality
Throbbing, synchronous with pulse.
Frequency
Periodic, cycles of several months to years
Duration
4 - 72 hours
Time and mode of onset
May be preceeded by prodromal stage
Onset after waking
Gets better with sleep
Associated Symptoms
Nausea, vomiting.
Irritability, swaeting
Photophobia, phonophonia
Prodromal symptoms of sensory, motor or psychic phemonena.
Family history.
Cluster headache
Site
Quality
Frequency
Duration
Time and mode of onset
Associated Symptoms
Site
Unilateral, radiating up and down from one eye
Quality
Severe, bone-crushing
Frequency
May have months or years between attacks.
Attacks occur in clusters over a period of 2 - 12 weeks
Duration
5 minutes to 3 hours
Time and mode of onset
Noctural, commonly awakens patient from sleep
Associated Symptoms
Facial flushing or pallpr
Unilateral lacrimation, ptosis and rhinitis
Secondary Headaches
Other types of headaches can be the first sign of a more serious illness. Headaches can partner with:
Subarachnoid haemmorrhage
Brain tumours
Other intracranial masses
Vascular abnormalities
Trigeminal neuralgia
Diseases of the eye, nose and teeth,
Systemic illness
Types of headaches
Nursing Care
Headaches
Conducting assessment to gather subjective and objective data is essential as patients presenting with acute and chronic headaches present one of the greatest challenges. Key details to obtain throughout the assessment is the location and type of pain, the onset, frequency, duration, and were there any precipitating events. It is also good to ask, what have they used to try and allievate the headache - what has worked and what hasn’t.
Priority care problems in the acute phase surround pain management, and any other symtpoms they may be experiencing depending on the type of headache they are presenting with. The use of both pharmacological and non-pharmcological treatments is effective at this stage.
Long term care problems include education especially around triggers and lifestyle modifications, keeping a headache diary and also stress management. Once again depending on the type of headaches will depend on the education and stategies provided.
Motor Neuron Disease - Nursing Management
There is a collaborative approach to managing MND patients. They need a coordinated interdisciplinary team approach that meets their needs, based on good teamwork and anticipating future difficulties. One important aspect of Motor Neuron disease is ensuring family have the option to undertake genetic testing and being put in contact with a genetic counselor. Due to the 10% incidence of familial MND (there is or has been more than one affected person in a family) the principles of genetic counselling and predictive testing to familial MND, should not be carried out without prior counselling. For further information see here: Familial MND and genetic testing
Key patient considerations for nurses to be aware of:
Nutritional status and weight loss;
Dysphagia monitoring - observing patients eating and drinking to avoid aspiration;
Pulse oximetry whilst eating to observe for decreased oxygen saturations;
Silent aspiration is common;
Educating the patient and family on maintaining adequate nutrition;
Liaising with dietics.
Gastrostomy management;
NGT hydration and nutrition;
Special consideration and planning for the patient’s eventual inability to communicate (prior planning can allow patients to use computers by signalling eye muscle movements or blinking).
Motor neuron disease
messages from the motor neurons gradually stop reaching the muscles. This will ultimately lead to muscles that are weakened, stiffen and wasted.
Motor neuron disease impacts how a person walks, talks, eats, drinks and breathes with this disease impacting everyone differently. There is no cure and the progession of symptoms impacts people at varying speeds.
Guillian-Barre syndrome (GBS) is
an acute, rapidly progressing neurological disorder. This is a rare disorder in which the body’s immune system mistakenly attacks part of its peripheral nervous system (National Institute of Neurological Disorders and Stroke, 2020). It may impact a person at any age, there is no disrimiation between the sexes and it can range from mild weakness to symetrical paralysis which leaves a person not being able to breath indendently.
Signs and symptoms to be looking for when nursing a patient with GBS:
Autonomic dysfunction;
Monitor for urinary retention;
Assess bulbar function;
Pain - narcotics or gabapentin often used and,
Nutritional support – may need enteral nutrition.
You will need to be aware of the following serious potential complications of this condition, and be mindful of these when performing routine vital signs and monitoring your patient:
Arrhythmias;
Paralytic ileus;
The potential need for IDC insertion;
SIADH (The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) in Guillain-Barré syndrome (GBS) is a very often overlooked entity even though it is well-described).
Nursing interventions for patients suffering from GBS
promoting respiratory function, monitoring neurological function, ensuring adequate hydration and nutrition, preventing immobility and thus pressure areas.
Collaborative management will involve liaising with the multidisciplinary care teams, such as physio and OT.
GBS Acute Stage
Begins with onset of symptoms, ends when no additional symptoms or deterioration are noted;
Severe and rapid weakness (especially in the lower limbs; loss of muscle strength progressing to quadriplegia and respiratory failure;
Decreasing deep tendon reflexes;
Decreased vital capacity;
Paraesthesias;
Pain;
ANS involvement manifested by bradycardia, sweating, fluctuating BP (notably hypotension);
1 to 3 weeks duration
GBS Stabilising/Plateau stage
Occurs 2-3 weeks after initial onset;
Marks the end of changes in the condition (symptoms ‘level’ off);
Autonomic functions stabilise;
May last days to weeks.
GBS Recovery stage:
Gradual improvement of signs and symptoms over months to 2 years;
Remyelination and regeneration occurring;
Improvement in symptoms;
Muscle strength and function gradually return descending order;
Huntington’s disease
a progressive, degenerative, inherited neurological disease characterised by increasing dementia and chorea (jerky, rapid, involuntary movements)”. The exact cause is unknown. It is a genetically inherited disease with no cure, exhibited by a decrease in GABA levels and ACh levels. The person does not exhibit Huntington’s disease until they are 30 to 40 years of age. People generally die for complications of this disease, 15-20 years after diagnosis and appearance of the initial symptoms. Complications are generally pneumonia, heart failure or infection developing from the body’s weakened condition.
After diagnosis, there are five stages of progression.
Early Stage - the person is diagnosed as having HD and can function fully both at home and work.
Early Intermediate Stage - the person remains employable but at a lower capacity. They are still able to manage their daily affairs despite some difficulties.
Late Intermediate Stage - the person can no longer work and/or manage household responsibilities. They need considerable help or supervision to handle daily financial affairs. Other daily activities may be slightly difficult but usually only require minor help.
Early Advanced Stage - the person is no longer independent in daily activities but is still able to live at home supported by their family or professional carers.
Advanced Stage - the person with HD requires complete support in daily activities and professional nursing care is usually needed.
Huntington’s Disease - Nursing Management
Primary goals as the disease progresses is to limit the risk of aspiration. This can be done by correct positioning of the patient, getting a swallow assessment by the Speech pathologist and following their recommendations for dietary requirements. This may be minced mashed or thickened drinks. If a person’s swallow becomes invariably affected, then Percutaneous endoscopic gastrostomy (PEG) may be required. PEG is an endoscopic medical procedure in which a tube is passed into a patient’s stomach through the abdominal wall, most commonly to provide a long term means of feeding when oral intake is not adequate (for example, because of dysphagia ). You need to be aware of choking first aid and positioning when performing PEG feeds.
In addition to the above, patients will require nutritional assessment. This will need to be adapted to ensure they are getting the correct calorie requirements for the changes to physical movement and exertion, in line with the stages of the disease process. You need to be monitoring for impaired skin integrity daily, and use of the Waterlow scale for accomplishment of skin assessment. Pressure injury assessment must be conducted each shift. Ensuring proper positioning, use of movement aids and adequate nutrition can prevent pressure injuries developing.
Multiple Sclerosis
Autoimmune destruction of myelin sheaths and oligodendrocytes. This leads to demyelination of axons which slows nerve conduction
Guillain-Barre Syndrome
Autoimmune degradation of the myelin sheath in peripheral neuron which slows transmission of signals in the peripheral nervous system, leading to loss of sensation and paralysis.
Huntington’s disease
Involves a deficiency of the neurotransmitters ACh and GABA which leads to movement disorder such as chorea and cognitive and psychiatric disorders.
Parkinson’s disease
Involves degeneration of the Dopamine-producing neurons in the substantia nigra of the midbrain, which in turn disrupts the normal balance between DA and acetylcholine in the basal ganglia.
Alzheimer’s disease
Occurs as a result of destruction of neurons in the hippocampus, limbic system and prefrontal cortex of the brain. The neurons affected are those which secrete acetylcholine and are thought to be damaged by excessive stimulation by glutamate.
Which regions in the CNS are affected in multiple sclerosis?
Show answer choices
White matter
X Grey matter X
Red matter
White and grey matter
From your understanding of the signs and symptoms of Parkinson’s disease answer the following 2 questions.
Dyskinesia is:
Show answer choices
Slowness of movement
involuntary, erratic, uncontrollable writhing movements of face, arms, legs or trunk
Limited or absent movements
involuntary but controllable writhing movements of face, arms, legs or trunk.
involuntary, erratic, uncontrollable writhing movements of face, arms, legs or trunk
Anosmia is:
Show answer choices
Loss of sense of smell- a non-motor symptom of Parkinson’s
Post-nasal drip
Dust-mite allergy
Incompetent cardiac sphincter with gastric acid aspiration
Loss of sense of smell- a non-motor symptom of Parkinson’s
A 50-yr-old man reports recurring headaches. He describes them as sharp, stabbing, and around his left eye. He says his left eye seems to swell and get teary when these headaches occur. Based on this history, you suspect he has:
Show answer choices
Cluster headaches
Tension headaches
Migraine headaches
Medication overuse headaches
Cluster headaches
During routine assessment of a patient with Guillain-Barre syndrome, the nurse finds the patient is short of breath. The patient’s respiratory distress is caused by:
Show answer choices
Elevated protein levels in the CSF
Immobility resulting from ascending paralysis
Degeneration of motor neurons in the brainstem and spinal cord
Paralysis ascending to the nerves that stimulate the thoracic area
Paralysis ascending to the nerves that stimulate the thoracic area
What characteristic of a patient’s recent seizure is consistent with a focal seizure?
Show answer choices
The patient lost consciousness during the seizure
The seizure involved lip smacking and automatisms
The patient fell to the ground and became stiff for approx 20 seconds
The aetiology of the seizure involved both sides of the patient’s brain
The seizure involved lip smacking and automatisms
In Activity 2 tutorial worksheet, you observed Lori having a tonic clonic seizure. Which of the following 2 actions are not immediate nursing actions:
Show answer choices
Time the seizure
Avoid restraining the patient
Check airway for obstruction
Leave the bed rails down
Hold the patient down so she doesn’t hurt herself
Assess LOC
Leave the bed rails down
Hold the patient down so she doesn’t hurt herself
The 2 (two) major neurotransmitters of concern in epilepsy are:
Show answer choices
Glutamate
Catecholamine
GABA
Histamine
Glutamate
GABA
Carbamazepine and Valproic acid both inhibit formation of action potentials in neurons? True or False?
True
