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Chapter 44

Care of Patients with Problems of the Central Nervous System: The

Brain

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Headaches

Migraine headache—chronic, episodic disorder with multiple subtypes

Stages: Prodrome Aura phase Headache phase

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Interventions

Recognize migraine symptoms Respond and see health care provider Relieve pain and associated symptoms

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Drug Therapy Abortive therapy—alleviating pain during

the early aura phase or soon after the headache has started

Preventive therapy

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Complementary and Alternative Therapies

Yoga, meditation, massage, exercise, biofeedback, relaxation techniques

Acupuncture Use of herbs and nutritional therapies with

approval Avoidance of trigger events that may

result in migraine episodes, such as tension and stress

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Cluster Headache

Histamine cephalalgia Cause unknown; attributed to

vasoreactivity and oxyhemoglobin desaturation

Unilateral, radiating to forehead, temple, or cheek

Ipsilateral tearing of the eye, rhinorrhea, ptosis, and miosis

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Therapy Same types of drugs used for migraines Patient to wear sunglasses and avoid

sunlight Oxygen via mask Avoidance of precipitating factors, such as

anger, excitement Surgical management

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Tension Headache Neck and shoulder muscle tenderness and

bilateral pain at the base of the skull and in the forehead

Head pain without associated symptoms Treatment—non-opioid analgesics, muscle

relaxants, occasional opioids Ibuprofen plus caffeine Prophylactic treatment similar to that used

in treating migraine headaches

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Seizures and Epilepsy Seizure—abnormal, sudden, excessive,

uncontrolled electrical discharge of neurons within the brain; may result in alteration in consciousness, motor or sensory ability, and/or behavior

Epilepsy—two or more seizures experienced by a person; chronic disorder with recurrent, unprovoked seizure activity, may be caused by abnormality in electrical neuronal activity and/or imbalance of neurotransmitters (e.g., GABA)

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Types of Seizures Generalized seizures Partial seizures Unclassified seizures

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Types

Primary or idiopathic epilepsy—not associated with any identifiable brain lesion

Secondary seizures—result from an underlying brain lesion, most commonly a tumor or trauma

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Seizures Risks

Seizures may result from: Metabolic disorders Acute alcohol withdrawal Electrolyte disturbances Heart disease High fever Stroke Substance abuse

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Nonsurgical Management

Antiepileptic drugs (AEDs) Importance of compliance Health teaching

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Seizure Precautions

Oxygen Suction equipment Airway IV access Siderails up No tongue blades

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Seizure Management

Will depend on the type of seizure Observation and documentation Patient safety Side-lying position No restraints

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Acute Seizure Management

Lorazepam Diazepam Diastat IV phenytoin or fosphenytoin

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Status Epilepticus

Medical emergency Prolonged seizures lasting more than 5

minutes or repeated seizures over the course of 30 minutes

Establish an airway ABGs IV push lorazepam, diazepam; rectal

diazepam Loading dose IV phenytoin

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Drug Therapy Evaluate most current blood level of

medication, if appropriate. Be aware of drug-drug and drug-food

interactions. Maintain therapeutic blood levels for

maximal effectiveness.

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Drug Therapy (Cont’d)

Do not administer warfarin with phenytoin. Document and report side and adverse

effects.

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Patient and Family Education

Antiepileptic drugs (AEDs) may not be stopped, even if seizures stop.

Refer limited-income patients to social services.

All states prohibit discrimination against people who have epilepsy.

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Patient and Family Education (Cont’d)

Alternative employment may be needed. Vocational rehabilitation may be

subsidized.

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Seizure Precautions Oxygen and suctioning equipment should

be readily available. Saline lock may be necessary. Siderails should be up at all times. Padded siderail use is controversial. Place bed in lowest position. Never insert padded tongue blades into

the patient’s mouth during a seizure.

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Seizure Management

If simple partial seizure, observe the patient and document the seizure.

Turn the patient on the side during a generalized tonic-clonic seizure; if possible, turn the patient’s head to prevent aspiration.

Cyanosis usually is self-limiting. Do not restrain.

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Surgical Management

Vagal nerve stimulation (VNS) Conventional surgical procedures Anterior temporal lobe resection Partial corpus callosotomy

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Meningitis Meningitis—inflammation of the meninges

that surround the brain and spinal cord Viral meningitis—usually self-limiting and

the patient has a complete recovery Bacterial meningitis—potentially life-

threatening

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Physical Assessment and Clinical Manifestations

Signs and symptoms of meningitis—headache, nausea, vomiting, and fever

Photophobia and indications of increased intracranial pressure

Nuchal rigidity and positive Kernig’s and Brudzinski’s signs

Seizure, decreased mental status, focal neurologic deficits

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Laboratory Assessment of Meningitis

Cerebrospinal fluid analysis Computed tomography scan Blood cultures Counterimmunoelectrophoresis Polymerase chain reaction Complete blood count X-ray study to determine presence of

infection

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Drug Therapy

Broad-spectrum antibiotic Hyperosmolar agents Anticonvulsants Steroids (controversial) Prophylaxis treatment for those who have

been in close contact with the meningitis-infected patient

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Encephalitis Inflammation of the brain tissue and

surrounding meninges Caused by viral agents, bacteria, fungi, or

parasites Degeneration of neurons of the cortex Hemorrhage, edema, necrosis, small

lacunae develop in cerebral hemispheres

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Hemorrhagic Encephalitis

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Interventions Prompt recognition and treatment of signs

of cerebral edema, hemorrhage, and necrosis of brain tissue

Establishment of patent airway Assessment of vital signs Continuous supportive care and

assessment

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Parkinson Disease

Progressive neurodegenerative disease that is the third most common neurologic disorder of older adults

Tremor, rigidity, bradykinesia, or akinesia Dopamine

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Parkinson Disease (Cont’d)

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Assessment Fatigue, slight tremor, problems with

manual dexterity Rigidity, changes in facial expression,

uncontrolled drooling, dementia, changes in voluntary movement, excessive perspiration, orthostatic hypotension

No specific diagnostic tests

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Drug Therapy in Parkinson Disease

Dopamine agonistsCatechol O-methyltransferases (COMTs)Monoamine oxidase type B (MAO-B)

inhibitorsDopamine receptor antagonists

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Drug Toxicity Long-term drug therapy regimens often

cause delirium, cognitive impairment, decreased effectiveness of the drug, or hallucinations.

Reduce medication dose. Change medications or frequency of

administration. Take “drug holiday,” especially in the use

of levodopa therapy.

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Management of Parkinson Disease

Exercise and ambulation Self-management Injury prevention Nutrition Communication Psychosocial support

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Management of Parkinson Disease (Cont’d)

Surgical management includes: Stereotactic pallidotomy/thalamotomy Deep brain stimulation Fetal tissue transplantation

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Alzheimer’s Disease Chronic, progressive, degenerative

disease that accounts for 60% of dementias occurring in people older than 65 years

Loss of memory, judgment, and visuospatial perception and change in personality

Increasing cognitive impairment, severe physical deterioration, death from complications of immobility

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Structural Changes in the Brain

Alzheimer’s disease creates changes that include: Neurofibrillary tangles Neuritic plaques Vascular degeneration Changes in neurotransmitters Increased amounts of an abnormal protein,

beta amyloid

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Manifestations Changes in cognition Alterations in communication and

language abilities Changes in behavior, personality, and

judgment Changes in self-care skills Psychosocial assessment, especially

patient’s reaction to changes in routine

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Interventions in Alzheimer’s Disease

Answer patient’s questions truthfully. Assess and treat other medical problems. Provide cognitive stimulation and memory

training. Structure the environment to increase

patient’s ability to function. Prevent overstimulation.

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Interventions Orientation and validation therapy. Promote self-management. Promote bowel and bladder continence. Assist with facial recognition. Promote communication.

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Drug Therapy

Donepezil, galantamine, rivastigmine Memantine Antidepressants Psychotropic drugs

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Risk for Injury Interventions for the patient with

Alzheimer’s disease include: Coping with restlessness and wandering;

ensuring patient wears identification bracelet; registering patient in Safe Return Program; providing frequent walks and structured activities

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Risk for Injury (Cont’d) Ensuring safety by removing all potentially

dangerous objects, particularly in case seizures occur

Minimizing agitation by talking calmly and softly; displaying positive affect; making calm movements; offering diversion

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Compromised Family Coping

Interventions for the caregiver role: Encourage family to seek legal counsel

regarding patient’s competency, need to obtain guardianship, or durable medical power of attorney, when necessary.

Make caregivers and family aware of their own health and stress resulting from new responsibilities for care.

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Disturbed Sleep Pattern

Difficulty sleeping at night with frequent naps in the day

Interventions for establishing sleep pattern: Re-establish the usual day-night pattern by

providing activity and exercise during the day. Establish before-bedtime ritual.

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Disturbed Sleep Pattern (Cont’d)

Adjust treatment and medication schedule to provide for uninterrupted sleep.

Give mild antianxiety agent or hypnotic.

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Huntington Disease

Hereditary disorder transmitted as an autosomal dominant trait at the time of conception

Movement disorder characterized by both neurologic and behavioral symptoms

Gradual clinical onset of progressive mental status changes, leading to dementia and choreiform movements in the limbs, trunk, and facial muscles

Three stages, each lasting about 5 years over an average 15 years of the disease

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Management of Huntington Disease

No known cure or treatment Genetic counseling Antipsychotic agents or monoamine-

depleting agents used to manage movement abnormalities that are disabling or interfere with ADLs

Medications to treat depression, anxiety, and obsessive-compulsive behaviors