The Neurologic System

Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458

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CHAPTER

Gerontological Nursing, Second EditionPatricia A. Tabloski

The Neurologic System

22Lecture Note PowerPoint Presentation




LEARNING OUTCOME 1Describe 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 22-1An 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 2Describe 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

MRILewy 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 22-4Plaques 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

http://en.wikipedia.org/wiki/Medical_procedure

http://en.wikipedia.org/wiki/Examination

http://en.wikipedia.org/wiki/Dead_body

http://en.wikipedia.org/wiki/Death

http://en.wikipedia.org/wiki/Disease

http://en.wikipedia.org/wiki/Injury




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

• 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 4Describe 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





• Processes at each level influence the next level

• Four quadrants direct symptom management– Caregiving environment– Social environment– Physical environment– Medical treatment





• 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 6Define 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 7Discuss 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– Anticoagulant therapy




Strokes

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




LEARNING OUTCOME 8Discuss 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 9Discuss 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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The Neurologic System

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