Neurologic and Spinal Cord Disorders (神经和脊髓疾病的护理)

MEDICALSURGICALNURSINGCaringforClientsWithNeurologicandSpinalCordDisordersDrIbraheemBashayreh,RN,PhD4/1/20111EPILEPSY

DEFINITION

Achronicneurologicdisordermanifestingbyrepeatedepilepticseizures(attacksorfits)whichresultfromparoxysmaluncontrolleddischargesofneuronswithinthecentralnervoussystem(greymatterdisease).Theclinicalmanifestationsrangefromamajormotorconvulsiontoabriefperiodoflackofawareness.Thestereotypedanduncontrollablenatureoftheattacksischaracteristicofepilepsy.4/1/20112PATHOGENESIS The19thcenturyneurologistHughlingsJacksonsuggested“asuddenexcessivedisorderlydischargeofcerebralneurons“asthecausationofepilepticseizures.Recentstudiesinanimalmodelsoffocalepilepsysuggestacentralrolefortheexcitatoryneurotransmiterglutamate(increasedinepi)andinhibitorygammaaminobutyricacid(GABA)(decreased)4/1/20113EPIDEMIOLOGYANDCOURSEEpilepsyusuallypresentsinchildhoodoradolescencebutmayoccurforthefirsttimeatanyage.4/1/20114EPILEPSYisasymptomofnumerousdisorders,butinthemajorityofsufferersthecauseremainsuncleardespitecarefulhistorytaking,examinationandinvestigation!

4/1/20115EPILEPSY&SEIZURES

Epilepsyisaneurologicaldisordercharacterizedbyrecurringseizuresalsoknownasa“seizuredisorder”Aseizureisabrief,temporarydisturbanceintheelectricalactivityofthebrain6Aseizureisasymptomofepilepsy4/1/2011THEBRAINISTHESOURCEOFEPILEPSY7Allbrainfunctions--includingfeeling,seeing,thinking,andmovingmuscles--dependonelectricalsignalspassedbetweennervecellsinthebrainAseizureoccurswhentoomanynervecellsinthebrain“fire”tooquicklycausingan“electricalstorm”4/1/2011EPILEPSY-CLASSIFICATIONThemodernclassificationoftheepilepsiesisbaseduponthenatureoftheseizuresratherthanthepresenceorabsenceofanunderlyingcause.Seizureswhichbeginfocallyfromasinglelocationwithinonehemispherearethusdistinguishedfromthoseofageneralisednaturewhichprobablycommenceinadeeperstructures(brainstem?thalami)andprojecttobothhemispheressimultaneously.4/1/20118EPILEPSY-CLASSIFICATIONFocalseizures–accountfor80%ofadultepilepsiesSimplepartialseizuresComplexpartialseizuresPartialseizuressecondarillygeneralisedGeneralisedseizuresUnclassifiedseizures4/1/20119CLASSIFYINGEPILEPSYANDSEIZURES

ClassifyingepilepsyinvolvesmorethanjustseizuretypeSeizuretypes:

Partial

GeneralizedSimple Complex Absence Convulsive10ConsciousnessismaintainedConsciousnessislostorimpairedAlteredawarenessCharacterizedbymusclecontractionswithorwithoutlossofconsciousness4/1/2011GROUPSATINCREASEDRISKFOREPILEPSYAbout1%ofthegeneralpopulationdevelopsepilepsyTheriskishigherinpeoplewithcertainmedicalconditions:MentalretardationCerebralpalsyAlzheimer’sdiseaseStrokeAutism114/1/2011WHATCAUSESEPILEPSY?Inabout70%ofpeoplewithepilepsy,thecauseisnotknownIntheremaining30%,themostcommoncausesare:Headtrauma

InfectionofbraintissueBraintumorandstroke HeredityLeadpoisoning Prenataldisturbancebraindevelopment124/1/2011SYMPTOMSTHATMAYINDICATEASEIZUREDISORDERPeriodsofblackoutorconfusedmemoryOccasional“faintingspells”EpisodesofblankstaringinchildrenSuddenfallsfornoapparentreasonEpisodesofblinkingorchewingatinappropriatetimesAconvulsion,withorwithoutfeverClustersofswiftjerkingmovementsinbabies134/1/2011SEIZURETRIGGERSMissedmedication(#1reason)Stress/anxietyHormonalchangesDehydrationLackofsleep/extremefatiguePhotosensitivityDrug/alcoholuse;druginteractions144/1/2011HOWISEPILEPSYDIAGNOSED?ClinicalAssessmentPatienthistoryTests(blood,EEG,CT,MRIorPETscans)NeurologicexamIDofseizuretypeClinicalevaluation tolookforcauses154/1/2011EPILEPSY

DIFFERENTIALDIAGNOSISThefollowingshouldbeconsideredinthediff.dg.ofepilepsy:SyncopeattacksCardiacarrythmiasMigraineHypoglycemia–seizuresorintermittentbehavioraldisturbancesmayoccur.Narcolepsy–inappropriatesuddensleepepisodesPanicattacks

PSEUDOSEIZURES–psychosomaticandpersonalitydisorders4/1/201116EPILEPSY–INVESTIGATIONTheconcernoftheclinicianisthatepilepsymaybesymptomaticofatreatablecerebrallesion.Routineinvestigation:Haematology,biochemistry(electrolytes,ureaandcalcium),chestX-ray,electroencephalogram(EEG). Neuroimaging(CT/MRI)shouldbeperformedinallpersonsaged25ormorepresentingwithfirstseizureandinthosepts.withfocalepilepsyirrespectiveofage.Specialisedneurophysiologicalinvestigations:SleepdeprivedEEG,video-EEGmonitoring.4/1/201117TYPESOFTREATMENTMedicationSurgeryNonpharmacologictreatmentKetogenicdiet:ahigh-fat,adequate-protein,low-carbohydratedietprimarilyusedtotreatdifficult-to-control(refractory)epilepsyinchildren

VagusnervestimulationLifestylemodifications184/1/2011EPILEPSY-TREATMENTThemajorityofptsrespondtodrugtherapy(anticonvulsants).Inintractablecasessurgerymaybenecessary.Thetreatmenttargetisseizure-freedomandimprovementinqualityoflife!Basicrulesfordrugtreatment:Drugtreatmentshouldbesimple,preferablyusingoneanticonvulsant(monotherapy).“Startlow,increaseslow“.Polytherapyistobeavoidedespeciallyasdruginteractionsoccurbetweenmajoranticonvulsants.Thecommonestdrugsusedinclinicalpracticeare:Carbamazepine,Sodiumvalproate,Phenytoin(firstlinedrugs)Lamotrigine,Topiramate,Levetiracetam,Pregabaline(newanti-epilepticdrugsAEDs)4/1/201119EPILEPSY–TREATMENT(CONT.)Ifptisseizure-freeforthreeyears,withdrawalofpharmacotherapyshouldbeconsidered.Withdrawalshouldbecarriedoutonlyifptissatisfiedthatafurtherattackwouldnotruinemploymentetc.(e.g.drivinglicence).Itshouldbeperformedverycarefullyandslowly!20%ofptswillsufferafurtherszwithin2yrs.4/1/201120EPILEPSY–SURGICALTREATMENTAproportionoftheptswithintractableepilepsywillbenefitfromsurgery.Epilepsysurgeryprocedures:Curative(removalofepilepticfocus)andpalliative(seizure-relatedriskdecreaseandimprovementoftheQOL)Curative(resective)procedures:Anteromesialtemporalresection,selectiveamygdalohippocampectomy,extensivelesionectomy,corticalresection,hemispherectomy.Palliativeprocedures:CorpuscallosotomyandVagalnervestimulation(VNS).

4/1/201121STATUSEPILEPTICUSAconditionwhenconsciousnessdoesnotreturnbetweenseizuresformorethan30min.Thisstatemaybelife-threateningwiththedevelopmentofpyrexia,deepeningcomaandcircullatorycollapse.Deathoccursin5-10%.Statusepilepticusmayoccurwithfrontallobelesions(incl.strokes),followingheadinjury,onreducingdrugtherapy,withalcoholwithdrawal,drugintoxication,metabolicdisturbancesorpregnancy.Treatment:AEDsintravenouslyASAP,event.generalanesthesiawithpropofolorthipentoneshouldbecommencedimmediately.4/1/201122POTENTIALLYDANGEROUSRESPONSESTOSEIZUREDONOTPutanythingintheperson’smouthTrytoholddownorrestrainthepersonAttempttogiveoralanti-seizuremedicationKeepthepersonontheirbackfaceupthroughoutconvulsion234/1/201123MULTIPLESCLEROSISisaninflammatorydiseaseinwhichthefattymyelinsheathsaroundtheaxonsofthebrainandspinalcordaredamaged,leadingtodemyelinationandscarringaswellasabroadspectrumofsignsandsymptomHighriskgroupsCaucasianfemalesAges:20–40FamilyhistoryCold,wet,northernU.S.MULTIPLESCLEROSISPathophysiologyAutoimmuneresponsewithviraltriggerDemyelinationSpinalcordBrainNervesoftheCNSMyelinreplacedwithplaqueImpulsetransmissioninterrupted/haltedMULTIPLESCLEROSIS(MS)ManifestationsExacerbations:Symptomsusuallyappearinepisodicacuteperiodsofworseningandremissions:ischaracterizedbyunpredictablerelapsesfollowedbyperiodsofmonthstoyearsofrelativequiet(remission)withnonewsignsofdiseaseactivity.ProgressionlongerexacerbationsTriggersforexacerbationsHeatSunInfectionsStressMULTISYSTEMEFFECTSOFMULTIPLESCLEROSIS.MULTIPLESCLEROSISLong-TermConsequencesUrinarytractinfectionsPressureulcers/jointcontracturesFallsPneumoniaDepressionMULTIPLESCLEROSIS-MEDICATIONSMedicationsImmunomodulatorsMonoclonalantibody:aremonospecificantibodiesthatarethesamebecausetheyaremadebyidenticalimmunecellsthatareallclonesofauniqueparentcell.SteroidsAntispasmoticsUrinaryagentsPharmacotherapyforfatigueMULTIPLESCLEROSIS–INTERDISCIPLINARYCAREOtherTherapiesPhysicaltherapySurgicalinterventionNeurectomy:isthesurgicalremovalofanerveorasectionofanerveRhizotomy:isaneurosurgicalprocedurethatselectivelyseversproblematicnerverootsinthespinalcord,mostoftentorelievethesymptomsofneuromuscularconditions.Plasmapheresis:isabloodpurificationprocedureusedtotreatseveralautoimmunediseasesNutritionalsupportMULTIPLESCLEROSIS–CLIENTTEACHINGClient/FamilyTeachingTriggersforexacerbations/stressorsMedications/sideeffectsCopingwithdeficitsCounseling/supportgroupsMULTIPLESCLEROSIS–NURSINGCAREAssessmentMotorassessmentMusclestrength;chewing/swallowingSensorychangesTingling;visionchangesMoodchangesUrinaryeliminationpatternsPastmedical/familyhistoryMULTIPLESCLEROSIS–NURSINGCAREAssessmentRespiratoryeffortADLsAppearanceMULTIPLESCLEROSIS–NURSINGCARENursingDiagnosesFatigueSelf-CareDeficitIneffectiveCopingImpairedMobilityRiskforInjuryMULTIPLESCLEROSIS–NURSINGCAREEvaluationADLCopingKnowledgelevelMedicationsDietComplicationsPARKINSON’SDISEASEMostcommonneurologicdisorderintheU.S.1.5millionaffectedMostcommonoverage40Caucasianmenvs.womenPARKINSON’SDISEASEPathophysiologyDeficiencyofdopamineAtrophyofcerebralcortexneuronsDecreaseddopaminereceptorsLossofinhibitionofacetylcholineConstantexcitementofmotorneuronsPARKINSON’SDISEASEManifestationsofParkinson’sCardinalsignsTremorRigidityBradykinesiaTremorRigidityofneck,shoulders,andtrunkBradykinesia:ischaracterizedbyslownessofmovementDrooling:salivaflowsoutsidethemouthPARKINSON’SDISEASE-MEDICATIONSMedicationsDopaminergicsDopamineagonistsAnticholinergicsMAOIsPARKINSON’SDISEASE–INTERDISCIPLINARYCAREOtherTherapiesSurgeryPallidotomy:isaprocedurewhereatinyelectricalprobeisplacedintheglobuspallidus(oneofthebasalgangliaofthebrain),whichisthenheatedtoto80degreescelsiusfor60s,todestroyasmallareaofbraincellsStereotactic

thalamotomy:isaninvasiveprocedure,primarilyeffectivefortremorssuchasthoseassociatedwithParkinson'sDisease(PD),whereaselectedportionofthethalamusissurgicallydestroyed(ablated).DeepbrainelectricalstimulationComplementarytherapyYogaMassageAcupuncturePARKINSON’SDISEASE–CLIENTTEACHINGClient/FamilyTeachingAssistivedevicesCommunicationtechniquesDecreasingaspirationriskSafetyDietExercisePARKINSON’SDISEASE–NURSINGCAREAssessmentCognition,moodMotorfunctioningFalls;stiffness;jerkingmovements“Pill-rolling”:Acircularmovementortremorofthetipsofthethumbandtheindexfingerwhenbroughttogether.FacialmuscleeffectsWeightloss;chewing/swallowingPARKINSON’SDISEASE–NURSINGCAREDiagnosesImpairedPhysicalMobilityImpairedVerbalCommunicationImbalancedNutrition:LessthanBodyRequirementsPARKINSON’SDISEASE–NURSINGCAREEvaluationAbilityto:AmbulateChewandswallowCommunicateComplicationsKnowledgelevelrelatedtodiseaseprocessMYASTHENIAGRAVISisanautoimmuneneuromusculardiseaseleadingtofluctuatingmuscleweaknessandfatigability.Womenages20–30ExacerbationsandremissionsTriggersforexacerbationsMYASTHENIAGRAVISPathophysiologyAuto-antibodiesfromthymusglandBlockacetylcholinereceptorsDecreasenumberofreceptorsBlockageofnerveimpulsesFace,lips,tongue,neck,andthroatCanaffectfinemotorskillsCanaffectrespiratorymusclesMYASTHENIAGRAVISManifestationsPtosis(isadroopingoftheupperorlowereyelid);diplopia(doublevision)SlurredspeechDifficultychewingandswallowingRespiratoryinsufficiencyFatigueAlteredfacialexpressionsDifficultywritingMYASTHENIAGRAVISLife-ThreateningComplicationsCholinergic

crisis:isanover-stimulationataneuromuscularjunctionduetoanexcessofacetylcholine(ACh),asofaresultoftheinactivity(perhapseveninhibition)oftheAChE

enzyme,whichnormallybreaksdownacetylcholineSeveremuscleweakness,nausea,vomitingSalivation,sweating,bradycardiaMyasthenia

crisis:isalife-threateningcondition,whichisdefinedasweaknessfromacquiredmyastheniagravis(MG)thatissevereenoughtonecessitateintubationortodelayextubationfollowingsurgery.Therespiratoryfailureisduetoweaknessofrespiratorymuscles.MuscleweaknessInabilitytoswallow;respiratorydistressMYASTHENIAGRAVIS-MEDICATIONSMed