Chapter 59: Nursing Management: Chronic Neurologic Problems

HEADACHE • The primary classifications of headaches include tension-type, migraine, and cluster headaches. o Tension-type headache, the most common type of headache, is characterized by its bilateral location and pressing/tightening quality. Tension-type headaches are usually of mild or moderate intensity and not aggravated by physical activity. o Migraine headache is a recurring headache characterized by unilateral or bilateral throbbing pain, a triggering event or factor, strong family history, and manifestations associated with neurologic and autonomic nervous system dysfunction. o Cluster headaches are a rare form of headache with a sharp stabbing pain. Cluster headaches involve repeated headaches that can occur for weeks to months at a time, followed by periods of remission. • • Therapies used in the treatment of headaches include drugs, meditation, yoga, biofeedback, cognitive-behavioral therapy, and relaxation training. Drug therapies include: o Tension-type: nonopioid analgesic is used alone or in combination with a sedative, muscle relaxant, tranquilizer, or codeine. o Migraine: analgesic, triptans, and preventive treatment (i.e., topiramate). o Cluster: drug therapy is not as useful as it is for the other types of headaches; prophylactic drugs may be prescribed. Headaches may be related to an inability to cope with daily stresses. The most effective therapy may be to help patients examine their lifestyle, recognize stressful situations, and learn to cope with them more appropriately. In addition to using analgesics and analgesic combination drugs for the symptomatic relief of headache, the patient should be encouraged to use relaxation techniques because they are effective in relieving tension-type and migraine headaches.

SEIZURE DISORDERS AND EPILEPSY • Seizure is a paroxysmal, uncontrolled electrical discharge of neurons in the brain that interrupts normal function. Seizures are often symptoms of an underlying illness. • • • Epilepsy is a condition in which a person has spontaneously recurring seizures caused by a chronic underlying condition. Seizures are divided into two major classes: generalized and partial. Generalized seizures involve both sides of the brain and are characterized by bilateral synchronous epileptic discharges in the brain from the onset of the seizure. Because the entire brain is affected at the onset of the seizures, there is no warning or aura. o Tonic-clonic seizure is characterized by loss of consciousness and falling to the ground if the patient is upright, followed by stiffening of the body (tonic phase) for 10 to 20 seconds and subsequent jerking of the extremities (clonic phase) for another 30 to 40 seconds. o Absence (petit mal) seizure usually occurs only in children and rarely continues beyond adolescence.

o Atypical absence seizure, which is characterized by a staring spell accompanied by other signs and symptoms, includes brief warnings, peculiar behavior during the seizure, or confusion after the seizure. • Partial seizures, also referred to as partial focal seizures, are caused by focal irritations. They manifest with unilateral manifestations that arise from localized brain involvement. o Simple partial seizures with elementary symptoms do not involve loss of consciousness and rarely last longer than 1 minute. o Complex partial seizures can involve a variety of behavioral, emotional, affective, and cognitive functions. These seizures usually last longer than 1 minute and are frequently followed by a period of postictal confusion. Status epilepticus is a state of continuous seizure activity or a condition in which seizures recur in rapid succession without return to consciousness between seizures. It is the most serious complication of epilepsy and is a neurologic emergency. Most seizures do not require professional emergency medical care because they are self-limiting and rarely cause bodily injury. However, if status epilepticus occurs, if significant bodily harm occurs, or if the event is a first-time seizure, medical care should be sought immediately. Seizure disorders are treated primarily with antiseizure drugs. Therapy is aimed at preventing seizures because cure is not possible. A significant number of patients whose epilepsy cannot be controlled with drug therapy are candidates for surgical intervention to remove the epileptic focus or prevent spread of epileptic activity in the brain. When a seizure occurs, the nurse should carefully observe and record details of the event because the diagnosis and subsequent treatment often rest solely on the seizure description. During the seizure it is important to maintain a patent airway. This may involve supporting and protecting the head, turning the patient to the side, loosening constrictive clothing, or easing the patient to the floor, if seated. Because many seizure disorders cannot be cured, drugs must be taken regularly and continuously, often for a lifetime. The nurse should ensure that the patient knows this, as well as the specifics of the drug regimen and what to do if a dose is missed.

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MULTIPLE SCLEROSIS • Multiple sclerosis (MS) is a chronic, progressive, degenerative disorder of the CNS characterized by disseminated demyelination of nerve fibers of the brain and spinal cord. • The cause of MS is unknown, although research findings suggest that MS is related to infectious (viral), immunologic, and genetic factors and is perpetuated as a result of intrinsic factors (e.g., faulty immunoregulation). MS is characterized by chronic inflammation, demyelination, and gliosis (scarring) in the CNS. The onset of the disease is often insidious and gradual, with vague symptoms occurring intermittently over months or years. Thus the disease may not be diagnosed until long after

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the onset of the first symptom. • • • • • • • The disease is characterized by chronic, progressive deterioration in some persons and by remissions and exacerbations in others. Common signs and symptoms of MS include motor, sensory, cerebellar, and emotional problems. Because there is no definitive diagnostic test for MS, diagnosis is based primarily on history, clinical manifestations, and the presence of multiple lesions over time as measured by MRI. Because there is currently no cure for MS, collaborative care is aimed at treating the disease process and providing symptomatic relief. Drug therapy used includes immunosuppressants, immunomodulators, and adrenocorticotropic hormone. Spasticity is primarily treated with antispasmodic drugs. However, surgery, dorsal-column electrical stimulation, or intrathecal baclofen delivered by pump may be required. Exercise improves the daily functioning for patients with MS not experiencing an exacerbation. Various nutritional measures have been used in the management of MS, including megavitamin therapy and diets consisting of low-fat and gluten-free food and raw vegetables. During an acute exacerbation the patient may be immobile and confined to bed. The focus of nursing intervention at this phase is to prevent major complications of immobility, such as respiratory and urinary tract infections and pressure ulcers. Patient teaching should focus on building general resistance to illness, including avoiding fatigue, extremes of heat and cold, and exposure to infection.

PARKINSON’S DISEASE • Parkinson’s disease (PD) is a disease of the basal ganglia characterized by slowness in the initiation and execution of movement, increased muscle tone, tremor at rest, and impaired postural reflexes. It is the most common form of parkinsonism. • The onset of PD is gradual and insidious, with a gradual progression and a prolonged course. It may involve only one side of the body initially. The classic manifestations of PD often include tremor, rigidity, and bradykinesia, which are often called the triad of PD. o Tremor can involve the hand, diaphragm, tongue, lips, and jaw but rarely causes shaking of the head. o Rigidity is the increased resistance to passive motion when the limbs are moved through their range of motion. o Bradykinesia is particularly evident in the loss of automatic movements, such as blinking of the eyelids, swinging of the arms while walking, swallowing of saliva, self-expression with facial and hand movements, and minor movement of postural adjustment. In addition to the motor signs of PD, many nonmotor symptoms are common. They include depression, anxiety, apathy, fatigue, pain, constipation, impotence, and short-term memory

impairment. • • Because there is no cure for PD, collaborative management is aimed at relieving the symptoms. Drug therapy for PD is aimed at correcting an imbalance of neurotransmitters within the CNS. Antiparkinsonian drugs either enhance the release or supply of dopamine (dopaminergic) or antagonize or block the effects of the overactive cholinergic neurons in the striatum (anticholinergic). Surgical procedures are aimed at relieving symptoms of PD and are usually used in patients who are unresponsive to drug therapy or who have developed severe motor complications. Diet is of major importance to the patient with PD because malnutrition and constipation can be serious consequences of inadequate nutrition. Patients who have dysphagia and bradykinesia need appetizing foods that are easily chewed and swallowed. Promotion of physical exercise and a well-balanced diet are major concerns for nursing care. Exercise can limit the consequences of decreased mobility, such as muscle atrophy, contractures, and constipation. Because PD is a chronic degenerative disorder with no acute exacerbations, nurses should note that teaching and nursing care are directed toward maintenance of good health, encouragement of independence, and avoidance of complications such as contractures.

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MYASTHENIA GRAVIS • Myasthenia gravis (MG) is an autoimmune disease of the neuromuscular junction characterized by the fluctuating weakness of certain skeletal muscle groups. • MG is caused by an autoimmune process in which antibodies attack acetylcholine (ACh) receptors, resulting in a decreased number of ACh receptor sites at the neuromuscular junction. The muscles most often affected by the fluctuating weakness are those used for moving the eyes and eyelids, chewing, swallowing, speaking, and breathing. The course of this disease is highly variable. Some patients may have short-term remissions, others may stabilize, and others may have severe, progressive involvement. Myasthenic crisis is an acute exacerbation of muscle weakness triggered by infection, surgery, emotional distress, drug overdose, or inadequate drugs. The major complications of MG result from muscle weakness in areas that affect swallowing and breathing. Drug therapy for MG includes anticholinesterase drugs, alternate-day corticosteroids, and immunosuppressants. Because the presence of the thymus gland in the patient with MG appears to enhance the production of AChR antibodies, removal of the thymus gland results in improvement in a majority of patients. Plasmapheresis can yield a short-term improvement in symptoms and is indicated for

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patients in crisis or in preparation for surgery when corticosteroids must be avoided. • The patient with MG who is admitted to the hospital usually has a respiratory tract infection or is in an acute myasthenic crisis. Nursing care is aimed at maintaining adequate ventilation, continuing drug therapy, and watching for side effects of therapy.

RESTLESS LEGS SYNDROME • Restless legs syndrome (RLS) is characterized by unpleasant sensory (paresthesias) and motor abnormalities of one or both legs. There are two distinct types of RLS, primary (idiopathic) and secondary. • • • The majority of cases are primary, and many patients with this type of RLS report a positive family history. The pathophysiology of primary RLS is related to abnormal iron metabolism and functional alterations in central dopaminergic neurotransmitter systems. The severity of RLS sensory symptoms ranges from infrequent minor discomfort (paresthesias, including numbness, tingling, and “pins and needles” sensation) to severe pain. The pain at night can produce sleep disruptions and is often relieved by physical activity such as walking, stretching, rocking, or kicking. Nonpharmacologic approaches to RLS management include establishing regular sleep habits, encouraging exercise, avoiding activities that cause symptoms, and eliminating aggravating factors such as alcohol, caffeine, and certain drugs. If nonpharmacologic measures fail to provide symptom relief, drug therapy may be started. The main drugs used in RLS are dopaminergic agents, opioids, and benzodiazepines.

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AMYOTROPHIC LATERAL SCLEROSIS • Amyotrophic lateral sclerosis (ALS) is a rare progressive neurologic disorder characterized by loss of motor neurons. ALS usually leads to death within 2 to 6 years after diagnosis. • • For unknown reasons, motor neurons in the brainstem and spinal cord gradually degenerate in ALS. The typical symptoms of ALS are weakness of the upper extremities, dysarthria, and dysphagia. Death usually results from respiratory infection secondary to compromised respiratory function. There is no cure for ALS, but riluzole (Rilutek) slows the progression. The illness trajectory for ALS is devastating because the patient remains cognitively intact while wasting away. The challenge of nursing care is to guide the patient in use of moderate intensity, endurance-type exercises for the trunk and limbs, as this may help to reduce ALS spasticity.

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HUNTINGTON’S DISEASE

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Huntington’s disease (HD) is a genetically transmitted, autosomal dominant disorder that affects both men and women of all races. The clinical manifestations are characterized by abnormal and excessive involuntary movements (chorea). These are writhing, twisting movements of the face, limbs, and body. The movements get worse as the disease progresses. Because there is no cure, collaborative care is palliative. Antipsychotic, antidepressant, and antichorea drugs are prescribed and have some benefit.