The Neurologic System: Lecture Note Powerpoint Presentation

CHAPTER
22
Lecture Note PowerPoint
Presentation
The Neurologic
System
Copyright ©2010 by Pearson Education, Inc.

Gerontological Nursing, Second Edition Upper Saddle River, New Jersey 07458
Patricia A. Tabloski All rights reserved.
LEARNING OUTCOME 1
Describe the components of the neurological
system.

Neurological System
• Central nervous system (CNS)
– Brain
– Spinal cord
• Peripheral nervous system
– Cranial nerves
– Spinal nerves
– Somatic nervous system
– Autonomic nervous system
– Reflex arc
Figure 22-1
An illustration of the right hemisphere of the brain. In dark brown, the cerebellum. In
beige, from bottom to top, the medulla oblongata and the pons. Just above it and slightly
lighter, the corpus callosum.
LEARNING OUTCOME 2
Describe progressive dementias.

Dementia
• Progressive disorder
• Characterized by a loss of cognition and at
least one of the following
– Ability to speak coherently and understand
language
– Ability to recognize or identify objects
– Ability to execute motor activities
– Ability to think abstractly, make sound
judgment, and plan and carry out complex
tasks
Dementia
• Aging is the greatest risk factor
• Clinical diagnosis
– Loss of intellectual ability with impairment that
interferes with social or occupational
functioning
– Delirium has been ruled out

Dementia
• Risk factors
– Delirium
– Mild cognitive impairment
– Vascular dementia

Dementia
• Types
– Alzheimer’s disease (AD)
 Abnormalities in the brain structure disrupts the
health of neurons
 Manifestations include memory failure, personality
changes, and difficulty with ADLs
 Causes
• Genetics
• Age
• Gender
• Race
• Head injury
• Environmental exposures
Dementia
• Types
– Vascular dementia
 Abrupt onset of dementia
 Focal neurological findings
 Low-density areas indicate vascular changes in
white matter
 Multiple strokes in CT or MRI present
 Unchanged personality
 Emotional problem

Dementia
• Types
– Lewy body dementia
 Clinical features persist over long period of time
resulting in severe dementia
 Lewy bodies and Lewy neuritis found in brain
structures
– Frontotemporal lobe dementia
 Diagnosed based upon personality changes
 Presence of frontal brain area atrophy in CT or
MRI
Lewy bodies : are abnormal aggregates of protein that develop inside nerve cells in
Parkinson's disease (PD) and Alzheimer's disease (AD) and some other disorders.
LEARNING OUTCOME 3
Discuss the stages of Alzheimer’s disease
and implications for nursing care.

AD
• Progressive disorder
• Results in the death of nerve cells
– Memory failure
– Personality changes
– Increasing inability to manage activities of
daily living

Figure 22-4
Plaques and tangles: The hallmark of AD.

AD
• Diagnosis
– History
– Physical examination
– Neuropsychological testing
– Definitive diagnosis: autopsy after death
Autopsy : is a medical procedure that consists of a thorough

examination of a body to determine the cause and manner of death
and to evaluate any disease or injury that may be present

AD
• Risk factors
– Advancing age
– Family history
– Head trauma
– Diabetes mellitus
– Clinical depression

AD
• Stages
– Stage 1, Mild
– Stage 2, Moderate
– Stage 3, Severe

Nurse’s Role
• Promote independence and autonomy
• Prevent complications
• Provide comfort
• Promote quality of life
• Education

Planning Care
• No cure available
• Goals of treatment
– Slow progression
– Manage manifestations
• Caregiver experience needed
– Long-term care
– End-of-life care

Planning Care
• Challenging behaviors and psychiatric
symptoms develop in the AD patient
• Settings used to care for AD patients
– Individual’s home or family member’s home
– Hospitals
– Long-term-care facilities (nursing homes)
– Congregate living facilities
– Hospice settings

Pharmacological Interventions
• Cholinesterase inhibitors
– Slow progression of symptoms
– Titrate dosages slowly
 Donepezil (Aricept)
 Rivastigmine (Exelon)
 Galantamine (Reminyl)

• Memantine (Namenda)
– N-methyl-d-aspartate (NMDA) antagonist
• Alternative and complementary therapies
– Vitamin E: limited support, more study needed
– Nonsteroidal anti-inflammatory drugs/statins:
patients taking these have reduced
development of AD
– Statins:are a class of drug used to lower cholesterol levels by inhibiting
the enzyme HMG-CoA reductase.

Environmental Safety
• Modify home to promote safety
• Door locks
• Secure rugs
• Decrease water heater temperature
• Handrails in bathroom

Functional Impairments
• Utilize therapeutic nonverbal behaviors
• Avoid fatigue, nonroutine activities, and
alcohol
• Avoid a high-stimulus environment
• Prevent disability
• Treat other conditions that lead to physical
decline

Functional Impairments
• Identify and respond rapidly to acute
changes in function
• Adapt care to accommodate neuromotor
changes secondary to progression of
dementia

Mood Disorders
• Be alert for changes
– Appetite
– Disinterest
– Anhedonia
– Sleep abnormality
– Fatigue

Delusions and Hallucinations
• Cause
– Delirium
– Interaction of dementia and personality
– Separate mental disorder coexisting with
dementia
– Disinhibition of cortical functions

Dependence in ADLs
• Promote, preserve functional
independence
• Preventive plans of care

Inability to Initiate Meaningful
Activities
• Results in apathy or agitation for dementia
sufferer
• Promote social involvements

Anxiety
• May be a primary disorder or a symptom
of depression
• May result from delusions, hallucinations,
or functional impairment
• Plan interventions to reduce stress,
enhance feelings of trust and safety
• Promote stability
• Provide diversion activities
Spatial Disorientation
• Results in incorrect interpretation of
objects or directions
• Results in fear, anxiety, suspicions,
illusions, delusions, and safety concerns
• Promote familiarity with environment
• Use landmarks to provide “pop-up” cues

Elopement
• means to run away, and to not come back
to the point of origination
• A valid concern in individuals with
cognitive impairments
• Risk factors
• Alzheimer’s Association Safe Return
Program

Resistance to Care
• Common in middle to late stages of
dementia
• Major reason for institutionalization and
use of psychotropic medications and
restraints
• Management strategies
– Restore calm
– Time-out

Food Refusal
• Occurs in each of the progressive stages
of AD
• Causes
• Management interventions

Insomnia
• Insomnia noted months prior to AD
diagnosis
• Establish routines to promote therapeutic
sleep patterns
– Establish sleep hygiene
– Eliminate stimuli before bedtime

Apathy and Agitation
• Associated with increasing cognitive
decline
• Escalation can result in violence and
combative behaviors
• Promote interest in the environment

• Used to promote comfort
• Begin with lower dosages and gradually
increase
• Monitor side effects closely

Late Stage Issues
• Institutionalization
• Do not resuscitate decisions
• Transfer to acute care facilities
• Feeding tubes
• Infections

LEARNING OUTCOME 4
Describe a contextual model to direct
behavioral and pharmacological
interventions for behavioral symptoms of
Alzheimer’s disease.

A Contextual Model for Symptom
Management for AD
• Core = dementia + personality
– Delusions – spatial disorientation = elopement
+ agitation
– Hallucinations – functional impairment
– Mood disorders – depression – anxiety +
inability to initiate meaningful activities –
apathy + repetitive vocalization + agitation +
insomnia
– Functional impairment – boredom – agitation
Management for AD
• Processes at each level influence the next
level
• Four quadrants direct symptom
management
– Caregiving environment
– Social environment
– Physical environment
– Medical treatment

Management for AD
• Nurse-directed care
– Approach focuses on prevention
– Nurses provide and suggest behavioral
strategies
– Add pharmacological interventions as last
resort

LEARNING OUTCOME 5
Discuss Parkinson disease in terms of
diagnosis, treatment strategies, and nursing
interventions.

Parkinson Disease
• Cause
– Loss of nerve cells
– Decreased dopamine
– Altered ratio of dopamine to acetylcholine
– Exact cause unknown

Risk Factors
• Aging
• Equality noted between races and sexes
• Genetics

Diagnostic Testing
• No specific testing
• Diagnosis made by excluding other
possibilities

Characteristics of Parkinson
Disease Stages
• Early stage
– One-sided symptoms
– Changes in posture, walking, and facial
expression
• Middle stage
– Difficulty rising from sitting position
– Maintain a flexed posture
• Late stage
– Inability to stand or walk
Pharmacological Therapies
• Sinemet
• Anticholinergics
• Amantadine
• Dopamine agonists

Surgical Management
• Unilateral posteroventral pallidotomy or
thalamotomy
• Brain stimulation surgery
• Transplantation of fetal midbrain
dopaminergic cells

Nursing Care
• Promote mobility
• Prevent falls
• Preserve independence
• Exercise

LEARNING OUTCOME 6
Define brain attack/stroke.

Stroke
• Rapid onset
• Loss of consciousness
• Results from a lack of blood perfusion to
the brain

Transient Ischemic Attack (TIA)
• Often called a “mini-stroke”
• Causes no permanent damage
• Increases risk of stroke in the future

Causes of Strokes
• Hemorrhage into the brain
• Embolus or thrombus that occludes an
artery
• Rupture of an extracerebral artery
resulting in subarachnoid hemorrhage

LEARNING OUTCOME 7
Discuss brain attack/stroke in terms of high-
risk older persons, treatment, and nursing
implications.

Strokes
• A leading cause of death
• 12:10,000 Americans will have a stroke
each year

Strokes
• Risk factors
– Hypertension
– Smoking
– Sedentary lifestyle
– Obesity
– Diabetes mellitus
– Excessive alcohol consumption
– Elevated cholesterol levels

Strokes
• Prevention
– Balanced diet and weight loss
– Exercise
– Tight glycemic control
– Reduction of high-risk behaviors
– Carotid endarterectomy: is a surgical procedure used
to prevent stroke, by correcting stenosis (narrowing)
in the common carotid artery. Endarterectomy is the
removal of material on the inside (end-) of an artery.
– Anticoagulant therapy

Strokes
• Treatment
– Establish airway
– Ventilation and oxygenation
– Assess neurological status
– Vital signs
– Rehabilitation

LEARNING OUTCOME 8
Discuss nursing interventions for seizures.

Nursing Care of the Patient with
Seizures
• Obtain medical history
• Review history of seizures
• Medication use
• Patient-family education
• Prevention of injury
• Monitor for status epilepticus
• Documentation

LEARNING OUTCOME 9
Discuss the difference between epilepsy and
seizures and nursing implications.

Seizure
• Abnormal, abrupt release of electrical
activity in the brain
• Results in a variety of symptoms
(spasticity, flaccidity)
• Manifestations based upon area of brain
affected

Epilepsy
• Two or more unprovoked seizures
• Incidence increases with age
– People older than 75 twice as likely to
develop new-onset epilepsy


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CHAPTER

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

Autopsy : is a medical procedure that consists of a thorough

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

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