ch59 Chronic Neurologic Problems
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Tension headache - site, quality, frequency, duration, time, symptoms:
- Bilateral, bandlike pressure at base of skull and/or face
- Constant squeezing tightness
- Cycles over several years
- Intermittent for months or years
- Not related to time
- Palpable neck and shoulder muscle stiffness, stiff neck, tenderness
Migraine headache - site, quality, frequency, time, symptoms:
- Unilateral (60%), may switch sides, commonly anterior
- Throbbing, synchronous with pulse
- Periodic, cycles of severaL months to years
- Continuous for hours or days
- May be preceded by prodrome, onset after awakening, better with sleep
- Nausea/vomiting, edema, irritability, sweating, photophobia, phonophobia, prodrome of sensory/motor/psych phenomena, family history (in 65%)
Cluster headache - site, quality, frequency, time, symptoms:
- Unilateral, radiating up or down from one eye
- Severe, bone-crushing
- May have months or years between attacks, attacks occur in clusters, 1-2x/day over a period of 4-8 wks
- 30-90 minutes
- Nocturnal, commonly awakens patient from sleep
- Vasomotor symptoms such as facial flushing or pallor, unilateral lacrimation, ptosis, rhinitis
Triptans (e.g., sumatriptan/Imitrex, almotriptan/Axert) are the first line of therapy for prevention of migraines. What effect does triptan have on arteries? What would be a contraindication?
- Vasoconstrict arteries
- Contraindicated in patients with hypertension
Treatment options for cluster headaches.
- Verapamil, lithium, ergotamine, divalproex, NSAIDS
- Inhaling 100% oxygen at 7-9 L/min x15-20 min.
- Sumatriptan (Imitrex)
- Methylsergode, if recurrence at a specific time
Treatment options for tension headaches.
Nonopioid analgesics (e.g., aspirin, acetaminophen) alone or with sedative, muscle relaxant, tranquilizer, or codeine.
- Involve both sides of the brain
- Characterized by bilateral synchronous epileptic discharges in brain from onset of seizure
- No warning or aura
- In most cases, loss of consciousness for a few seconds to several minutes
- Most common generalized seizure (f.k.a. grand mal)
- Loss of consciousness
- Fall on ground
- Tonic = fall to ground, stiff body for 10-20 seconds
- Clonic = subsequent jerking phase for 30-40 seconds
- Loss of body function control (salivation, incontinence) may occur
Typical absence seizure (petit mal):
Brief staring spell, lasts only a few seconds, often unnoticed. Usually occurs only in children, rarely beyond adolescence. EEG demonstrates 3-Hz spike-and-wave pattern unique to this type of seizure.
Atypical absence seizure:
Staring spell with other symptoms including brief warnings, peculiar behavior during seizure, or confusion after seizure. EEG demonstrates atypical spike-and-wave patterns, usually >3 Hz.
- Unilateral manifestations, localized in brain, caused by focal irritations
- Begin in specific region of cortex
- May be confined to one side of brain or may spread to involve entire brain, culminating in generalized tonic-clonic seizure
Multiple sclerosis episodes of flair-up followed by remission are due to:
Demyelination of nerve sheath followed by myelin regeneration.
In multiple sclerosis, damage to nerve axons occurs and myelin is replaced with:
Glial scar tissue, which forms hard, sclerotic plaques and results in slowing/blockage of nerve impulses.
Medications to treat multiple sclerosis:
- Corticosteroids - exacerbations
- Immunomodulators - exacerbations
- Immunosuppressants - exacerbations
- Cholinergics - urinary retention
- Anticholinergics - urinary frequency/urgency
- Muscle relaxants - spasticity
- CNS stimulants - fatigue
- Antiviral/antiparkinsonian - fatigue
Define Parkinson's disease.
Disease of basal ganglia characterized by slowness in initiation and execution of movements (bradykinesia), increased muscle tone (rigidity), tremor at rest, and impaired postural reflexes.
- First sign: Tremor
- Second sign: Rigidity
- Third sign: Bradykinesia
Parkinson's disease medication therapy:
- Dopaminergics - enhance supply of dopamine
- Anticholinergics - block effect of overactive cholinergic neurons
Parkinson's disease first drug of choice:
- Levodopa + carbidopa = Sinemet
- Levodopa is chemical precursor to dopamine, crosses blood-brain barrier, converts to dopamine in basal ganglia; carbidopa inhibits enzyme dopa-decarboxylase in peripheral tissues, allowing more levodopa to get to the brain.
Define myasthenia gravis.
- An autoimmune disease in which antibodies attack acetylcholine (ACh) receptors, resulting in decreased number of ACh receptor sites on neuromuscular junctions.
- Characterized by fluctuating weakness, with rest restoring strength and progressing weakness through the day.
Myasthenic crisis r/t myasthenia gravis:
- Acute exacerbation of muscle weakness triggered by infection, surgery, emotional distress, drug overdose, or inadequate drugs.
- Major complications are muscle weakness with swallowing and breathing.
Myasthenia gravis medication therapy:
- Anticholinesterase drugs - enhance function at the neuromuscular junction, prolongs action of acetylcholine by inhibiting enzyme that brakes down acetylcholine; includes neostigmine (Prostigmin) and pyridostigmine (Mestinon).
- Alternate-day corticosteroids.
Cholinergic crisis r/t myasthenia gravis:
Overdose of anticholinesterase drugs (used to treat myasthenia gravis), resulting in respiratory insufficiency and severe muscle weakness.
Myasthenia gravis related crisis: Differentiating between myasthenic crisis and cholinergic crisis.
- Administer Tensilon (anticholinesterase drug)
- Symptoms improve = myasthenic crisis
- Symptoms worsen = cholinergic crisis
Myasthenia gravis surgical option:
Thymus gland produces anticholinesterase; therefore, removing the thymus gland (thymectomy) results in improvement in majority of patients.
Define amyotrophic lateral sclerosis (ALS).
Progressive wasting disorder, loss of motor neurons, leads to death within 2-6 years of diagnosis. Weakness of limbs progressively moving inward until respiratory failure results in death. Patients remain cognitively intact.
Nursing interventions for amyotrophic lateral sclerosis (ALS):
- Facilitate communication
- Reduce risk of aspiration
- Decrease pain secondary to muscle weakness
- Decrease risk of injury related to falls
- Provide diversional activities such as reading and companionship
- Help family and patient manage disease process including grieving related to loss of motor function and ultimately death
Define Huntington's disease.
Autosomal dominant (50% chance of inheritance), deficiency in acetylcholine and GABA, symptoms opposite of Parkinson's. Excessive, abnormal involuntary movements (chorea), writhing, twisting movements. Progressive disease. Death usually within 10-20 years.
Care for the patient with Huntington's disease:
- Palliative care
- Antipsychotics (Haldol), antidepressants, and antichorea (clonazepam/Klonopin)
- High-calorie diet (4000-5000 kCal/day)
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