I.

Neurological System: Normal Aging Process

Brain:

In the chronological order of the aging process brain function which was once stable during most of
adulthood, begins to decline. The brain does not decline in a unilateral order, rather certain aspects of the
brain and their function decline at different times and declining of brain function may vary from person to
person.

o Short-term memory and the ability to learn new material tend to be affected relatively early.
o Verbal abilities, including vocabulary and word usage, begin to decline at about age 70.

o Intellectual performance—the ability to process information (regardless of speed)—is usually

maintained until about age 80 if no neurologic disorders are present.

o Reaction time and performance of tasks may become slower due to the slower processing of nerve
impulses by the brain.
As aging progresses, the number of neurons in the brain is usually decreased, however loss is on a
case-by-case basis, depending on the person's health. In addition the remaining nerve cells function less
effectively. To compensate for the losses of neurons the brain employs the following:

o Redundancy: The brain has more cells than it needs to function normally; which may help
compensate for the loss of nerve cells that occurs with aging and disease.
o Formation of new connections: The brain actively compensates for the age-related decrease in
nerve cells by making new connections between the remaining nerve cells.
o Production of new nerve cells: Some areas of the brain may produce new nerve cells,
especially after a slight brain injury or a stroke. Which would explain how people who have
had a brain injury or stroke can sometimes learn new skills, as occurs during occupational
therapy.

Lifestyle, like for everything else in life, plays a factoring how quickly brain function declines. For
example, a healthy lifestyle consisting of mental (such as brain teasers and puzzles) and physical (running
and yoga) exercise seems to slow the loss of nerve cells in areas of the brain involved in memory. Such
exercise also helps keep the remaining nerve cells functioning albeit at only a degree. On the other hand, an
unwholesome lifestyle, for example consuming two or more drinks of alcohol a day can speed the decline
in brain function.
 • Normal Physiological Changes of the Brain due to Aging
o Blood flow to the brain may decrease by an average of 20%.
o The brain atrophies as a result of aging process.
o The brain weight decreases
o A decrease in enzymes, protein and lipids in brain tissue are also the norm.
o A shrinkage of large neurons resulting in loss of large neurons with an increase in smaller
neurons.
o Alterations in the amount of neuro-transmitters.
Spinal Cord:
During aging, the disks between vertebrae become less elastic even hard and brittle, and parts of
the vertebrae may hypertrophy. As a result, the disks lose their capacity to cushion stress on the vertebrae,
so more pressure is put on the spinal cord and on the spinal nerve roots. The increased pressure may injure
some sensitive and minute nerve fibers in the spinal cord. Such injury can result in decreased sensation and
sometimes decreased strength and balance, leading to safety issues among the elderly.
Peripheral Nerves:
As we age, peripheral nerves may conduct impulses more slowly, and consequently in decreased
sensation, slower reflexes, and often some clumsiness. Nerve conduction slows because myelin sheaths
degenerate. Degeneration occurs due to the blood flow decreasing, nearby bones overgrowing and put the
added pressure on the nerves, or both. In a non-diseased older adult, the effect may be so minute that no
change in function is noticeable; unless nerves are injured by something else a frequently culprit is
diabetes.
The peripheral nervous system's response to injury is also reduced. In comparison to a person’s youth
when damaged axons of peripheral nerves have the ability to repair itself so long as its body, in close
proximity to the spinal cord is undamaged, in older adults this regenerative process more slowly and
incompletely, increasing an older adults risk for injury and vulnerable to disease.
• Other Changes due to the Aging Neurologic System of the Older Adult:

o Clinical changes due to the above are decreased sensation of vibrations (notably in legs),
less brisk deep tendon reflexes with ankle reflex absent entirely and a decreased ability
for upward gaze.
o Functional changes include slowing of response to tasks and the increase in time to
recover from physical exertion
o Cognitive changes include memory loss, decrease in perceptual ability and decrease
in proficiency.
II. Neurological Physical Assessment of an Older Adult
Neurologic examination for elderly patients, similar to that for any adult, includes evaluation of
cranial nerves, motor function, sensory function, and mental status.
 It is noted however that non-neurologic disorders that are common among elderly people may
complicate the assessment. For example, visual and hearing deficits may impede evaluation of cranial
nerves, and periarthritis (inflammation of tissues around a joint) affecting certain joints, especially
shoulders and hips, may interfere with evaluation of motor function.
Findings are taken with background knowledge of the patient's age, history, and other findings.
Symmetric findings unaccompanied by functional loss and other neurologic symptoms and signs may be
noted in elderly patients.
1. Cranial nerves:

a. Elderly people often have small pupils; their pupillary light reflex may be sluggish,
and their pupillary mitotic response to near vision may be diminished.

b. Upward gaze and, to a lesser extent, downward gaze are slightly limited.

c. Eye movements, when tracking a physician's finger during evaluation of visual

fields, may appear jerky and irregular.

d. Bell's phenomenon (reflex upward movement of the eyes during closure) is

sometimes absent.

e. In many elderly people, sense of smell is diminished because they have fewer
olfactory neurons, have had numerous upper respiratory infections, or have chronic
rhinitis. However, asymmetric loss (loss of smell in one nostril) is abnormal.

f. Taste may be altered because the sense of smell is diminished or because patients
take drugs that decrease salivation.

g. Visual and hearing deficits may result from abnormalities in the eyes and ears rather
than in nerve pathways.

2. Motor function: Strength, coordination, gait, and reflexes are evaluated.

a. Elderly people, particularly those who do not do resistance training regularly, may
appear weak during routine testing. For example, during the physical examination,
the nurse may easily straighten a patient's elbow despite the patient's effort to sustain
a contraction. If weakness is symmetric, does not bother the patient, and has not
changed the patient's function or activity level, it is likely to be clinically
insignificant.
b. Increased muscle tone, measured by flexing and extending the elbow or knee, is a
normal finding in elderly people; however, jerky movements during examination and
cogwheel rigidity are abnormal.

c. Tremors are examined during handshaking and other simple activities. If tremor is
detected, amplitude, rhythm, distribution, frequency, and time of occurrence (at rest,
with action, or with intention) are noted.

d. A decrease in muscle mass (sarcopenia) is a common age-related finding. It is

insignificant unless accompanied by a decline or change in function (eg, a patient is
no longer able to rise from a chair without using chair arms). Sarcopenia affects the
hand muscles (eg, interosseous and thenar muscles) in particular.

e. Weak extensor muscles of the wrist, fingers, and thumb are common among patients
who use wheelchairs because compression of the upper arm against the armrest
injures the radial nerve. Having the patient pick up an eating utensil or touch the
back of the head with both hands can test arm function.

f. Motor reaction time and motor coordination are tested. Reaction time often decreases
with aging, partly because conduction of signals along peripheral nerves slows.

g. Coordination decreases because of changes in central mechanisms, but this decrease

is usually subtle and does not impair function.

h. The deep tendon reflexes are checked. Aging usually has little effect on them.
However, eliciting the Achilles tendon reflex may require special techniques (eg,
testing while the patient kneels with the feet over the edge of a bed and with the
hands clasped). A diminished or absent reflex, present in nearly ½ of elderly patients,
may be normal. It occurs because tendon elasticity decreases and nerve conduction in
the tendon's long reflex arc slows. Asymmetric Achilles tendon reflexes may indicate
sciatica.

i. Overall postural control is evaluated using the Romberg test (patients stand with feet
together and eyes closed). With aging, postural control is often impaired, and
postural sway (movement in the anteroposterior plane when the patient remains
stationary and upright) may increase.

j. Cortical release reflexes (known as pathologic reflexes), which include snout,

 sucking, and palmomental reflexes, occasionally occur in elderly patients who have
no detectable brain disorders (eg, dementia).

k. Babinski's reflex (extensor plantar response) in elderly patients is abnormal; it

indicates an upper motor neuron lesion, which is often cervical spondylosis with
partial cord compression.

3. Sensation: Evaluation of sensation includes touch (using a skin prick test), cortical sensory
function, temperature sense, proprioception , and vibration sense testing. Aging has limited
effects on sensation.

a. Many elderly patients report numbness, especially in the feet. It may result from a
decrease in size of fibers in the peripheral nerves, particularly the large fibers.
Nonetheless, patients with numbness should be checked for peripheral neuropathies.
In many patients, no cause of numbness can be identified.

b. Many elderly people lose vibratory sensation below the knees. This loss occurs
because small vessels in the posterior column of the spinal cord change. However,
proprioception, which is thought to use a similar pathway, is unaffected.

4. Mental status: A mental status examination is a key component of evaluation. A patient who
is disturbed by such a test should be reassured that it is routine. The examiner must make sure
that the patient can hear; hearing deficits that prevent a patient from hearing and
understanding questions may be mistaken for cognitive dysfunction. Evaluating the mental
status of a patient who has a speech or language disorder (eg, mutism, dysarthria, speech
apraxia, aphasia) can be difficult.

a. Orientation may be normal in many patients with dementia or other cognitive

disorders. Thus, evaluation may require questions that identify abnormalities in
consciousness, judgment, calculations, speech, language, praxis, executive function,
or memory, as well as orientation. Abnormalities in these areas cannot be attributed
solely to age, and if abnormalities are noted, further evaluation, including a formal
test of mental status, is needed.
b. With aging, information processing and memory retrieval slow but are essentially
unimpaired. With extra time and encouragement, patients perform such tasks
satisfactorily.
III. Five Common Neurological Disorders among Older Adults and their Management

01. Parkinson’s Disease: A chronic (long term) progressive degenerative neurological disorder affecting
the brain centers that are responsible for control and regulation of movement
Pathophysiology
o Coordination problems
o Degeneration of substanita nigra (pigmented neurons) leads to depletion of Dopamine
causing decreased and slowed voluntary movements, rigidity and tremors
o With the Decrease in Dopamine(Inhibits excitability) you have an increase in
Acytlcholyene(h excitability). That’s why you have the tremors, rigidity, and slow
movements
Incidence
o Begins most often in 5th decade of life
o Affects men and women equally – whites more than blacks
o Not a familial disease
Etiology
o May Follow
a. Acute encephalitis (viral infection ) – RARE
b. Carbon monoxide, metallic or other poisoning
c. Sometimes associated with arteriosclerosis
o Cause is unknown
Diagnosis
o Clinical Manifestations form history
o Must have 2 of the 3 cardinal symptoms
o No Conclusive lab work
o Handwriting changes may be first clue
o May take a while to diagnose
Prognosis
o Symptoms come on rapid in first year and then level off
o Advance of symptoms most often extended over several decades
Clinical Manifestations
o Resting tremors - Pill-rolling tremors
a. Disappears with purposeful movement
o Intentional Tremor – Piggyback – hold hand
o Muscle rigidity (cogwheel rigidity) – prevents from doing normal activity
a. Jerky PROM
 o Akinesia / Bradykinesia
a. Absence of movement / Slow movement
o Mask-like facial expression
a. Have a stare and eyes may not blink
o Moist oily skin
o Monotonous, low pitched, slow poorly articulated speech
o Drooling
a. Due to problems swallowing secondary to muscle problems R/F
Aspiration
o Heat intolerance
o Intellect is not affected – Do not treat them as if it is affected
o Characteristic Propulsion Gait
a. Forward stoop, with a tendency to get going too fast where they
are unable to stop
b. Shuffling gait, walk on toes, take tiny steps, and do not have
normal movement with hands and arms = potential safety problems
HRF Injury
o Appetite increased but can’t eat much because of drooling and difficulty swallowing
resulting in weight loss.
o Impaired handwriting
a. First sign although not a cardinal symptom
b. Handwriting gets small and shaky looking
o Deficits in judgment and emotional instability
o Intention tremors
a. When attempting to do something like pick up a glass
o Depression – Common
o Decreased cerebral blood flow = dementia
o All signs and symptoms increase with fatigue, excitement, and frustrations
a. As a nurse you would: Not let them get too tired, excited, or
frustrated
o Complications form immobility (Pneumonia, UTI) and the consequences of falls and
accidents are major causes of death
Medical Management
o There is no known treatment
Drug therapy
o Anticholinergic drugs – Causes constipation in elderly
 o These drugs are either used to hDopamine supply or i Achytocholine response
a. Congentin – Control tremor and rigidity
b. Artaine – Same as Congentin
c. Levadopa – Replaces or converts to Dopamine in basal ganglia;
usually given with Sinemet to allow increased levels of Dopamine
d. Symmetrel – Antiviral – rigidity, tremors, and bradykenisa
e. Sinemet – 3 main symptoms
Surgical Treatment
o Destroy part of brain tissue in thalamus - Thalamectomy
o Effective for younger people
o Surgery not used often on elderly, usually use the meds instead – Levadopa
Nursing Management
o Physical Therapy / Gait training
o Teach to use wide gait and look ahead which forces them to keep the head up
o Teach patient to exercise for posture and prevent deformities
o Keep neck straight and prevent contractures
o Can lead to respiratory problems
o No pillows under the neck causes flexion of the neck
o Weigh periodically – Intake problems
o Rest and eating appropriately
o Speech Exercises – May need voice amplifier
o Constipation problems – possibly due to drooling
o Weakness of the muscles needed to defecate
o Do oral care and protect skin around the mouth – drooling
o May have problem eating – getting food to mouth and chewing – have suction
available
o Lassitude (exhaustion)
o Tremor control – Hold on to chair or hold one hand in the other
o General health measures
o Patient and/or family education
o Medications – SE
o Exercise and walking
o Well-balanced diet – Usually regular diet
o Small frequent feedings
o Warming plate for food
 o Over the counter meds must be Ok’d by MD
o Cannot have Vitamin B6: Fortified breads and cereals may have Vitamin B6
Parkinson’s Crisis
o Medical Emergency- See sudden severe exacerbation of classic symptoms – call for
immediate attention – not able to swallow, walk, sweating, tachycardia, etc.
o Results form sudden withdrawal of anti-parkinsonian medications or some severe
emotional trauma
o Can die from this – quiet environment may give sedative-hypnotic, anticonvulsants
and antiparkinson’s meds IV
o First calm patient and be sure patient is breathing
o Provide respiratory and cardiac support
o May be given an injection of Phenobarbital
02. Dementia
Alzheimer’s type is a specific degenerative process occurring primarily in the cells located at the
base of the forebrain that send information to the cerebral cortex and hippocampus. It is the most common
form of dementia and is characterized by a steady and global decline.
Vascular dementia reflects a pattern of intermittent deterioration related to multiple infarcts to
various areas of the brain. Although the etiologies differ, these two forms of dementia share a common
symptom presentation and therapeutic intervention.
Signs and Symptoms
Early dementia

o Word-finding difficulty - May be able to compensate by using synonyms or defining

the word
o Forgetting names, appointments, or whether or not the person has done something; losing
things
o Difficulty performing familiar tasks - Driving, cooking a meal, household chores,
managing personal finances
o Personality changes (for example, sociable person becomes withdrawn or a quiet person
is coarse and silly)
o Uncharacteristic behavior
o Mood swings, often with brief periods of anger or rage
o Poor judgment
o Behavior disorders - Paranoia and suspiciousness
o Decline in level of functioning but able to follow established routines at home
o Confusion, disorientation in unfamiliar surroundings - May wander, trying to return to
 familiar surroundings
Intermediate dementia
o Worsening of symptoms seen in early dementia, with less ability to compensate
o Unable to carry out activities of daily living (eg, bathing, dressing, grooming, feeding,
using the toilet) without help
o Disrupted sleep (often napping in the daytime, up at night)
o Unable to learn new information
o Increasing disorientation and confusion even in familiar surroundings
o Greater risk of falls and accidents due to poor judgment and confusion
o Behavior disorders - Paranoid delusions, aggressiveness, agitation, inappropriate sexual
behavior
o Hallucinations
o Confabulation (believing the person has done or experienced things that never happened)
o Inattention, poor concentration, loss of interest in the outside world
o Abnormal moods (anxiety, depression)
Severe dementia
o Worsening of symptoms seen in early and intermediate dementia
o Complete dependence on others for activities of daily living
o May be unable to walk or move from place to place unassisted
o Impairment of other movements such as swallowing - Increases risk of malnutrition,
choking, and aspiration (inhaling foods and beverages, saliva, or mucus into lungs)
o Complete loss of short- and long-term memory - May be unable to recognize even close
relatives and friends
o Complications - Dehydration, malnutrition, problems with bladder control,
infections, aspiration, seizures, pressure sores, injuries from accidents or falls.
Etiological Theories
o Psychodynamics
These forms of dementia reflect a chronic organic mental disorder with progressive cognitive
losses caused by damage to various areas of the brain, depending on underlying pathology.
Personality change is common and may be manifested by either an alteration or accentuation of
premorbid characteristics with primary deficits in memory and planning and a predisposition to
confusion.
o Biological Theories
 Vascular dementia reflects a pattern of intermittent deterioration in the brain. Symptoms
fluctuate and are determined by the area of the brain that is affected. Deterioration is
thought to occur in response to repeated infarcts of the brain. Predisposing factors include
 cerebral and systemic vascular disease, hypertension, cerebral hypoxia, hypoglycemia,
cerebral embolism, and severe head injury.
 Several studies have shown that antibodies are produced in the brains of individuals with
Alzheimer’s disease. Although the triggering mechanism is not known, the reactions are
actually autoantibody production, suggesting a possible alteration in the body’s immune
system. Although the exact cause of Alzheimer’s disease is unknown, several hypotheses
have been supported by varying amounts and quality of research data.
CLIENT ASSESSMENT DATA BASE
Activity/Rest
o Feeling tired; fatigue may increase severity of symptoms, especially as evening approaches
o Day/night reversal; wakefulness/aimless wandering, disturbance of sleep rhythms
o Lethargy; decreased interest in usual activities, hobbies; inability to recall what is read/follow
plot of television program; possibly forced to retire
o Impaired motor skills; inability to carry out familiar, purposeful movements
o Content sitting and watching others
o Main activity may be hoarding inanimate objects; repetitive motions (e.g., fold-unfold-refold
linen), hiding articles, or wandering
Circulation
o Possible history of systemic/cerebral vascular disease, hypertension, embolic episodes
(predisposing factors)
Ego Integrity
o Behavior often inconsistent; verbal/nonverbal behavior may be incongruent
o Suspicious or fearful of imaginary people/situations; clinging to significant other(s)
o Misperception of environment, misidentification of objects/people, hoarding objects; belief
that misplaced objects are stolen
o Multiple losses; changes in body image and self-esteem
o Emotional/ability (cries easily, laughs inappropriately); variable mood changes (apathy,
lethargy, restlessness, short attention span, irritability); sudden angry outbursts (catastrophic
reactions)
o May deny significance of early changes/symptoms, especially cognitive changes, and/or
describe vague, hypochondriacal reports (e.g., fatigue, diarrhea, dizziness, occasional
headaches)
o May conceal limitations (e.g., make excuses for not being able to perform tasks; thumbing
through a book without reading it)
o Feelings of helplessness; strong, depressive overlay; delusions; paranoia
Elimination
 o Urgency (may indicate loss of muscle tone)
o Incontinence of urine/feces
o Prone to constipation/impaction, with diarrhea
Food/Fluid
o Hypoglycemic episodes (predisposing factor)
o Lack of interest in/forgetting of mealtimes; dependence on others for food cooking and
preparation at table, feeding, using utensils
o Changes in taste, appetite; denial of hunger/refusal to eat (may be trying to conceal lost skills)
o Loss of ability to chew (silent aspiration
o Weight loss; decreased muscle mass; emaciation (advanced stage)
Hygiene
o May be dependent on SO to meet basic hygiene needs
o Appearance disheveled, unkempt; body odor present; poor personal habits
o Clothing may be inappropriate for situation/weather conditions
o Misinterpretation of, or ignoring, internal cues, forgetting steps involved in toileting self, or
inability to find the bathroom
Neurosensory
o Concealing inabilities (may make excuses not to perform task, may thumb through a book
without reading it)
o Family members may report a gradual decrease in cognitive abilities, impaired judgment/
inappropriate decisions, impaired recent memory but good remote memory, behavioral
changes/individual personality traits altered or exaggerated
o Loss of proprioception sense (location of body/body parts in space)
o Primitive reflexes (e.g., positive snout, suck, palmar) may be present
o Facial signs/symptoms dependent on degree of vascular insults
o Seizure activity (secondary to the associated brain damage) may be reported/noted
o Mental status (may laugh at or feel threatened by exams)
o Disoriented to time initially, then place; usually oriented to person until late in disease process
o Impaired recent memory, progressive loss of remote memory
o May change answers during the interview
o Difficulty in comprehension, abstract thinking
o Unable to do simple calculations or repeat the names of three objects, short attention span
o Hallucinations, delusions, severe depression, mania (advanced stage)
o May have impaired communication: difficulty with finding correct words (especially nouns);
conversation repetitive or scattered with substituted meaningless words; speech may become
inaudible; gradually loses ability to write (fine motor skills) or read
Safety
o History of recent viral illness or serious head trauma, drug toxicity, stress, nutritional
deficits (may be predisposing/accelerating factors)
o Incidental trauma (falls, burns, etc.); presence of ecchymosis, lacerations
o Disturbance of gait
o Striking out/violence toward others
Social Interactions
o Possibly fragmented speech, aphasia, and dysphasia
o May ignore rules of social conduct/inappropriate behavior
o Prior psychosocial factors (individuality and personality influence present altered
behavioral patterns)
o Family roles possibly altered/reversed as individual becomes more dependent
Teaching/Learning
o Family history of DAT (4 times greater than general population); incidence of primary
degenerative dementia is more common in women (who live longer) than in men; vascular
dementia occurs more often in men than in women
o May present a total healthy picture except for memory/behavioral changes
o Use/misuse of medications, OTC drugs, alcohol
Diagnostic Studies
Note: Although no diagnostic studies are specific for Alzheimer’s disease, these studies are used to rule out
reversible problems that may be confused with these types of dementia.
o Antibodies: Abnormally high levels may be found (leading to a theory of an immunological
defect).
o ApoE4: Screens for the presence of a genetic defect associated with the common form of
DAT.
o CBC, RPR, Electrolytes, Thyroid Studies: May determine or eliminate treatable/reversible
dysfunctions (e.g., metabolic disease processes, fluid/electrolyte imbalance, neurosyphilis).
o Vitamin B12: May disclose a nutritional deficit, if low.
o Folate Levels: Low level can affect memory function.
o Dexamethasone Suppression Test (DST): Rules out treatable depression.
o ECG: Rules out cardiac insufficiency.
o EEG: May be normal or show some slowing (aids in establishing treatable brain
dysfunctions), they may also reveal focal lesions (vascular).
o Skull X Rays: Usually normal but may reveal signs of head trauma.
o Vision/Hearing Tests: Rule out deficits that may be the cause of or contribute to
disorientation, mood swings, altered sensory perceptions (rather than cognitive impairment).
 o Positron-Emission Tomography (PET) Scan, Brain Electrical Activity Mapping (BEAM),
Magnetic Resonance Imaging (MRI): May show areas of decreased brain metabolism
characteristic of DAT. (In the future, scans may become a screening tool to reveal early
changes, such as plaque formation or development of neurofibrillary tangles, for those at risk
of developing dementia.)

o CT Scan: May show widening of ventricles, or cortical atrophy.

o CSF: Presence of abnormal protein from the brain cells is 90% indicative of DAT.
o Tropicamide (Mydriacyl) Pupil Response Test: Hypersensitive to drugs that block the action
of acetylcholine. Pupil dilation response to the eyedrops seems equal in clients with mild or
early-stage DAT as in severe stage; therefore, this test may provide an early screening tool but
is still being researched.
o Alzheimer’s Disease–Associated Protein (ADAP): Postmortem studies have yielded positive
results in more than 80% of DAT patients. Adaptation of ADAP for live testing is being
investigated.
Nursing Management
o Provide safe environment; prevent injury.
o Promote socially acceptable responses; limit inappropriate behavior.
o Maintain reality orientation/prevent sensory deprivation/overload.
o Encourage participation in self-care within individual abilities.
o Promote coping mechanisms of client/significant other(s).
o Support client/family in grieving process.
o Provide information about disease process, prognosis, and resources available for
assistance.
Discharge Goals
o Adequate supervision/support systems available.
o Maximal level of independent functioning achieved.
o Coping skills developed/strengthened and using available resources.
o Disease process/prognosis and client expectations/needs understood
o Plan in place to meet needs after discharge.

03. Seizures & Epilepsy

o Paroxysmal uncontrolled abnormal discharge of electrical activity in the brain
o Malfunction of hypersensitive neurons in cerebral cortex & limbic centers
Classification according to etiology
 Primary / Unknown – assessment finding does not reveal a definite cause
  Secondary / Symptomatic – causes
• Hyperpyrexia
• CNS infection
• Cerebral hypoxia &/or trauma
• Toxic agents / poison; metabolic intoxication
• Brain defects
• Degenerative diseases
• anaphylaxis
o Generalized – usually begins bilaterally without local onset, EEG abnormalities
 Grand Mal / Generalized Tonic-Clonic Seizure
• Precede by an aura (strange feeling of sensation)
• Loss of consciousness
• Tonic phase – entire body stiffens in rigid contractions, fixed jaw,
clenched fists, temporary interruption of respiration (30-60s duration)
• Clonic phase – rhythmic jerky contraction & relaxation of muscles
(esp. extremities), may bite lip 7 tongue, may be followed by fatigue,
confusion, depression, amnesia
 Petit Mal / Absence seizure
• No actual convulsive movement
• Vacant stare
• Childhood or early adolescence
• No recall of attack
o Partial / Focal Seizure – most common; depends on brain part involved
 Jacksonian / Simple Partial Motor Seizure
• Tonic-clonic convulsive movement in a localized body region opposite
of lesion
• Usually without loss of consciousness
Priorities
 Priorities: airway & safety
 Provide privacy
 Ensure patent airway
• Side-lying position
• Padded tongue depressor
o Prevent injury
 Raise padded side rails
  Do not leave client alone (stay with client until fully conscious)
 D not attempt to restrain
 Protect the head (slip a small pillow under; place on lap)
o Reorient client to surroundings upon waking
o Note position of eyeball & head at the beginning of attack
o Note duration of unconsciousness
o Observe for fecal or urinary involvement
o
o Causes:
 Head trauma – most common cause (closed head injuries)
 Brain tumors
Risk factors:
 CVA
 CNS infections
 Toxic substances interfering with brain metabolism (O 2 & glucose supply) –
lead, alcohol & substance abuse
 Genetic pre-disposition (cerebral dysrhythmia, monozygotic twins)
Diagnostic Exams
o Neurologic assessment
 Mental status exam
o EEG (electroencephalogram) – determines existence & type of epilepsy
 Hair shampoo (Prior & after the test)
 Hold meds (sedatives, tranquilizers, stimulants) & foods with caffeine 2-3days
prior
o Skull x-rays – reveals skull configuration
 Remove metallic objects
o Computerized Tomography (CT) scan – visualization of brain & its structures in
successive layers; IV contrast medium may be used
 Secure consent
 NPO at least 4hrs prior
 √ for seafood allergy
 C/I: pregnant, obese, claustrophobic, unstable v/s , a llergy to the dye
o MRI
o Positron-emission Tomography (PET) – visualization of physiologic functions; client is
given doses of strong radioactive tracers
  Secure consent
 NPO 4hrs prior
 If diabetic client, CBG <>
 Agitated clients may require sedation
Pharmacologic management - to control or minimize seizure
o IV
 Phenobarbital (Sodium luminal)
 Phenytoin (Dilantin)– slow cardiac arrhythmias & prevent seizures
 Diazepam (Valium) – muscle relaxant
o Oral – maintenance dose
 Carbamazepine (Tegretol)- anti-convulsant
 Dilantin
Nursing Management
 Help client identify precipitating factors (stress, lack of sleep, alcohol use)
 No alcoholic beverages
 Take meds religiously
 Caution in swimming, horse-back riding, & driving
 Provide support to clients to accept condition & live a life as normal as possible
 Psychosocial counseling
 Carry IDs stating client is epileptic
Surgery – last resort; client does not respond to meds
 Cortical resection of anterior temporal lobe – safest & most effective
• Criteria: failure of medical approach & localization of a focus of
abnormal electrical discharge
• Client must be awake the whole time
 Brain tumor surgery
Status epilepticus – continuous seizures or rapid succession lasting for at least 30mins
 A medical emergency
 Client may remain comatose & have repetitive seizure for hours
 Precipitating factor: abrupt withdrawal of anti-convulsant meds
 Lorazepam (Ativan) slow IV – med of choice given until seizures stop (Valium
or Dilantin may be used instead)
• Ventilation equipment must be ready
 General anesthesia may be used or Vecuronium bromide (Norcuron –
neuromuscular blocker)
  Client must be on continuous EEG monitoring

04. Cerebrovascular Accident (CVA, Stroke) Definition: decreased blood supply to the brain Risk
factors

o hypertension, uncontrolled
o smoking
o obesity
o increased blood cholesterol and triglycerides
o chronic atrial fibrillation

Five classes of stroke: by severity

o transient ischemic attack (TIA), "angina" of the brain

o TIA is warning sign of stroke
o localized ischemic event
o produces neurological deficits lasting only minutes or hours
o full functional recovery within 24 to 48 hours
o reversible ischemic neurological deficit (RIND)
o similar to TIA
o findings last between 24 hours and three weeks
o usual full functional recovery within three to four weeks
o partial, nonprogressing stroke: some neurological deficit, but stabilized
o progressing stroke (stroke in evolution)
o deteriorating neurological status often with grand mal seizure activity
o with residual neurological deficits
o completed stroke

Two types of stroke by cause

C. ischemic (also known as occlusive) stroke (clot) - slower onset

o results from inadequate blood flow leading to a cerebral infarction
o caused by cerebral thrombosis or embolism within the cerebral blood vessels
o most common cause: atherosclerosis
D. hemorrhagic stroke (bleeding) - abrupt onset
o intracerebral hemorrhagic stroke
o blood vessels rupture with a bleed into the brain
 o occurs most often in hypertensive older adults
o may also result during anticoagulant or thrombolytic therapy
o subarachnoid hemorrhage (SAH)
o most often caused by rupture of saccular intracranial aneurysms
o more than 90% are congenital aneurysms
o epidural bleeds
o arterial is involved
o often loss of consciousness for a short period or called transient
o recall clue: associate that "e" in epidural and "a" in artery are together
at the top of the alphabet
o subdural bleeds
o vein is involved
o may not be evident until months after the initial trauma
o recall clue: associate that "s" in subdural and "v" in vein are together at
the bottom of the alphabet

Diagnostics

o History and physical exam

o Computerized tomogram (CT) scan
o Magnetic resenance imaging (MRI)
o Doppler echocardiography flow analysis
o Carotid artery duplex doppler ultrasonography
o EEG - shows electrical activity
o Lumbar puncture - shows if blood found in cerebral spinal fluid
o Cerebral angiography - shows blood flow
o may be done with or without contrast

Types of CVA

Management - to prevent or minimize the damaging effects of stroke; dependent on the type of CVA

Expected outcomes:

a. prevent or minimize the damaging effects of stoke

 b. is dependent on type of type of CVA

o Occlusive stroke
a. pharmacologic

o thrombolytics
o anticoagulant therapy: heparin, coumadin
o antiplatelet therapy: aspirin, dipyridamole
1. platelet aggregation inhibitor: clopidogrel (plavix),
ticlopidine HCL (ticlid)
o steroids: dexamethasone

b. surgery - bypass
o Hemorrhagic stroke
a. pharmacologic

o antihypertensive agents
o systemic steroids: dexamethasone (decadron)
o osmotic diuretics: mannitol
o antifibrinolytic agents: aminocaproic acid (amicar)
o vasodilators
o alpha-blockers and beta-blockers
o anticonvulsants

b. surgical excision of aneurysm

o Common to both types of stroke

o care based on findings

o therapies:
1. occupational
2. speech
3. nutritional support

Nursing interventions

o In acute stage of stroke

• maintain airway patency; if grand mal seizure activity note time,

 length, behaviors
• monitor neuro vital signs
• maintain adequate fluids
• provide activity as ordered
• perform passive and/or active range of motion exercises
• position with head of bed elevated 15 to 30 degrees with client turned
or tilted to unaffected side
• maintain proper body alignment
• administer medications as ordered
• care for post op client as indicated
• provide care for client with increased intracranial pressure

o Long-term care of client with stroke

• monitor elimination patterns

• teach/evaluate the use of supportive devices
• maintain a safe environment
• prevent the effects of immobility
• maintain adequate nutrition in light of feeding and swallowing
problems
• assist with eating and ADL as indicated
• provide emotional support
• provide methods of communication for client with aphasia
1. 05. Delirium- “ acute confusional state”
oDisturbances of consciousness
oChange in cognition
oDevelopment over a short period of time
2. Key Symptoms
oF EARFULNESS
oD ISORIENTATION
oA GITATION
3. Etiology:
o UNKNOWN
o General Medical condition
o CHF, Pneumonia, Uremia, Malnutrition, dehydration, cancer, CVA and etc.
o Substance
 o Prescription drug intoxication like anticholinergic drugs combination (elavil,
antihistamines, antispasmodics, analgesics, steroids, sedatives, cardiovascular drugs
(digoxin and diuretics) and cimetidine.)
4. Management:
oTreatment of underlying disease and judicious use of medications and manipulation of
the environment.
5. Psychopharmacology
o Hypoactive delirium – no specific meds
o Hyperactive – sedation
o Haloperidol (.5 to 1mg)
o NO benzodiazepine
o Except if caused by alcohol – benzodiazephines
o Restraints