Neurology Ch. 65

Management of patients with oncologic or degenerative neurologic

disorders

Brain Tumors

Pathophysiology• Primary– Originating from the

brain

• Secondary– Originating outside the

brain– Metastasis

Brain Tumors

• Malignant– Tend to become

progressively worse– Anaplasia

• Cell distortion

– Invasive

• Benign– No malignant or

recurrent

Brain Tumors

• Presence of lesion • Compression of blood

vessels • Ischemia • Edema • I-ICP

Brain Tumors

• Are brain tumors a disorder of the CNS, PNS or Both the CNS and PNS?

A. CNSB. PNSC. Both CNS & PNS

Primary-Brain Tumors

Etiology• Unknown

Brain Tumors

Clinical manifestations• Depends on– Size– Location

Brain Tumors

4 main S&S• I-ICP– Cushing sign– H/A– Vomiting– Visual disturbances

• Seizures• Hydrocephalus• Alt Pituitary function

• Cancer cells being attacked by immune system

Brain Tumors

Localized S&S• Frontal– Personality changes– Emotional changes

• Occipital– Visual impairment– Visual hallucinations

• Cerebellum– Impaired equilibrium– Impaired coordination

Brain Tumors

Diagnosis• CT• MRI

Primary - Brain Tumors

Medical management• Radiation• Chemotherapy• Pharmaceutical– Corticosteroids– Anti-convulsants

• Surgery

• Tug McGraw

Secondary-Brain Tumor

3 treatment options• No treatment– Death < 1 month

• Tx w/ corticosteroids only– Death < 2 months

• Tx with radiation– Death 3-6 months

Secondary-Brain Tumor

Pharmacology• Corticosteroids– Dexamethasone– Prednisone

• Osmotic Diuretic– Mannitol

• Anti-convulsants– Dilantin

• Morphine

Brain Tumors

Nursing Management• Aspiration• Alt. nutrition– Cachexia

• Weak emaciate condition

• Neuro checks• Photophobia• Seizure precaution• Anxiety

Brain Tumors

• What S&S are associated with frontal lobe, occipital lobe and cerebellum tumors?

• What diet would you expect a patient with brain cancer to be on?

• The S&S are associated with increase intracranial pressure?

Brain Tumors

• What are the difference between malignant tumors and benign tumors?

• What does metastasis refer to?• What are risk factors of cancer?• What does remission mean or refer to?

Parkinson’s Disease

• First described by James Parkinson 1817

• A progressive brain disorder characterized by the degeneration of dopamine secreting neurons deep in the cerebral hemisphere in a part of the brain called the basal ganglia

Parkinson’s Disease

• Basal Ganglia– Controls movement

• Dopamine– Inhibitory

neurotransmitter in the basal ganglia

• Acetylcholine– Excitatory

neurotransmitter in the basal ganglia

Parkinson’s Disease

• Without dopamine, inhibitory influences are lost and excitatory mechanisms are unopposed

• Neurons of basal ganglia are over stimulated

• Excess muscle tone, tremors & rigidity

Parkinson’s Disease

• Is Parkinson's disease a disorder of the CNS, PNS or both the CNS & PNS?

A. CNSB. PNSC. Both PNS & CNS

Parkinson’s Disease

Clinical manifestations• Onset– Abrupt

• Age of on set– 60

• Men vs. Women– Men > women

• First Symptom– Fine tremors in hands or

feet

Parkinson’s Disease

3 clinical signs• Tremors• Rigidity• Bradykinesia

Parkinson’s Disease

• Tremors– Resting tremor– with activity– tremor when…

• Walking• Anxious

– Sensation of heat– Calorie burning!

Parkinson’s Disease

• Rigidity– Stiffness

• Neck• Trunk• Shoulders

– Posture• Head bowed• Body bent forward• Arms flexed• Thumbs turned into

palms• Knees bent (slightly)

Parkinson’s Disease

• Bradykinesia– Slow movement– Akinesia

• Loss of movement• Esp face

– Expressionless

– Slow speech• Dysphonia

– Dysphagia• Drooling

Parkinson’s Disease

• Bradykinesia– Gait

• Shuffled• Festination

– Fall forward d/t posture

Parkinson’s Disease

Diagnosis• S&S• Positive response to

Levodopa

Parkinson’s Disease

Medical Management• dopamine– (blood brain barrier)

Parkinson’s Disease

• Anti-Parkinsonian medications– Levodopa

• Converts into dopamine in the basal ganglia

• Works best in 1st few years of disease effectiveness wanes

• S/E Dizzy (esp when first get up) get up slowly!

Parkinson’s Disease

• Anti-Parkinsonian medications– Sinemet

• Prevents the breakdown of levodopa outside the brain

Parkinson’s Disease

Nursing Management• Assessment– Affect on ADL’s– Dysfunction– S/E of meds

Parkinson’s Disease

Nursing Management• Improving mobility– Exercise– ROM– Warm baths– Massage– PT

• gait program

Parkinson’s Disease

Nursing Management• Enhancing Self-care– Encouragement– Adaptive devices– OT

Parkinson’s Disease

Nursing Management• Improving Bowel

elimination – Constipation– Bowel routine– Fluids– Fiber– Raised toilet

Parkinson’s Disease

Nursing Management• Nutritional deficit– Slow process– Meds dry mouth– Chewing & Swallowing– Weights– Supplement– Dietician

• FORK!

Parkinson’s Disease

Nursing Management• Enhance swallowing– Upright position– Semi-solid food– Thick liquids

Parkinson’s Disease

Nursing Management• Communication– Speak slow– Short sentences– Deep breath before

speaking– SLP

Parkinson’s Disease

• With PD it is known which neurotransmitter is lacking in the brain and scientists are able to duplicate this neurotransmitter. Why are we then unable to cure PD?

• PD type deterioration of the nerve cells of the brain reduces the amount of what neurotransmitter?

• Because of the inability to cure PD at this time, PD is frequently treated with which medications?

• What are the side effects of these meds?

Parkinson’s Disease

• To promote optimal functions, which activity could the nurse recommend as being beneficial to a patient with PD ?

• What would be of value in helping a patient with PD communicate with the medical team?

• Is PD a disease of the CNS, PNS or both?

Parkinson’s Disease

• During an assessment, what signs and symptoms can the nurse anticipate a patient with Parkinson’s to exhibit?

• What nursing diagnosis would be priority for a patient with Parkinson’s?

• Describe the muscle tone of a patient with Parkinson’s (medical terms)

• What interventions can be used to address the issue of nonintention tremors?

Huntington’s Disease

• AKA– Huntinton’s Chorea

• Pathophysology– Rare– Genetic

• George Huntington

Huntington’s Disease

• The disease is characterized as degeneration of the cerebral cortex and the basal ganglia

Huntington’s Disease

– Which causes chronic progressive chorea • Bizzare involuntary dance-

like movements

– And mental deterioration

– Ending in dementia and death

• Loss of GABA (inhibitory neurotransmitter)

Huntington’s Disease

Clinical manifestations• Involuntary choreiform• Diminished during sleep• Facial tics/grimacing• Paranoia &

hallucinations• Appetite– Ravenous

• Emotions– Labile

Huntington’s Disease

Diagnosis• DNA testing

Huntington’s Disease

Medical management• No treatment• Meds to tics– Chlorpromazine

(Thorazine)• Meds to hallucination,

delusions, angry outbursts– Haloperidol (Haldol)

• Anti-psychotics

Huntington’s Disease

Nursing Management• Family support• Diet• Ambulatory• Safety

Huntington’s Disease

• Is Huntington’s a disease of the CNS, PNS, or both?

• What dietary changes might be appropriate for a patient with Huntington’s disease?

• Describe the pathophysiology of Huntington’s disease.

• What is the etiology of Huntington’s disease?

• How is Huntington’s disease different from Parkinson’s disease?

Huntington’s Disease

• What medications are used to help with tics and uncontrolled movements associated with Huntington Chorea?

• If a patient expresses suicidal thought, what are the correct nursing management interventions

• Huntington’s Chorea is characterized by what (what does it look like)?

• Name five nursing interventions for a patient with Huntington’s disease

Amyotrophic Lateral Sclerosis

Pathophysiology• Degenerative motor

neuron disease that affects UMN & LMN lying within the brain, spinal cord and peripheral nerves

• Lou Gehrig

Amyotrophic Lateral Sclerosis

• The myelin sheaths are destroyed and replaced with scar tissue

Amyotrophic Lateral Sclerosis

• Does not affect CN– 3– 4– 6

• The patient is therefore able to – Blink– Move eye

Amyotrophic Lateral Sclerosis

• Cognition is left intact!

Amyotrophic Lateral Sclerosis

• Is ALS a disorder of the CNS, PNS or both the CNS and PNS?

A. CNSB. PNSC. Both CNS & PNS

Amyotrophic Lateral Sclerosis

Etiology• Unknown• Men vs. Women– Men > Women

Amyotrophic Lateral Sclerosis

Clinical manifestations• Progressive muscle

weakness• Atrophy• Spasity• Dysphagia• Dysarthria• Jaw Clonus• Tongue fasciculation

Amyotrophic Lateral Sclerosis

Clinical Manifestations• No sensory loss• Death within 5 years– Resp. failure– Bulbar paralysis

Amyotrophic Lateral Sclerosis

Diagnosis• S&S only– No dx screen

Amyotrophic Lateral Sclerosis

Medical Management• Baclofen (Lioresal)• Diazepan (Valium)– Spasticity

• Mechanical Ventilator

Amyotrophic Lateral Sclerosis

Nursing Management• Respiratory• ADL’s• Nutritional support• Emotional support• Advanced directive

Amyotrophic Lateral Sclerosis

• Amyotrophic Lateral Sclerosis is manifested by what?

• What are the classic signs and symptoms of this disease?

• What are fasciculations?• Amyotrophic lateral sclerosis effects UMN, LMN or

both?• CNS? PNS? Both?• What is the treatment methodology for ALS?• What is the pathophysiology of ALS?

Herniated Disc

• AKA– Ruptured disc– Slipped disc– Degenerative disc

disease

Herniated Disc

• Anatomy– The interverterbral disc

is a cartilaginous plate that forms a cushion between the vertebral body

– Nucleus pulposus– Protrudes– Nerve compression

Herniated Disc

Etiology• Age• Trauma

Herniated Disc

Clinical Manifestations• Cervical– Location

• C5-6• C6-7

– Pain • Neck • Shoulder• ? Heart attack?

Herniated Disc

• Lumbar– Location

• L4-5• L5-S1

– Pain• Low back• Sciatica

– Relieved with• Bed rest

Herniated Disc

Medical Management• Conservative - cervical– Immobilization

• Collar

– Isometric exercises– Pain relief

• Hot packs• Analgesics• Muscle relaxant med• Anti inflammatory med

Herniated Disc

Medical Management• Conservative - lumbar– Bed rest

• Firm mattress

– Pain relief• Hot packs• Analgesics• Massage• Muscle relaxant med• Anti inflammatory med

Herniated Disc

Medical management• Surgery – lumbar– Turning

• Log roll

– Sitting• No sitting (except BR)

– Complication• Failed Disc Syndrome

Herniated Disc

• What are contributing factors to a Herniated disc?

• The center of the vertebral disc is called what?

• What are the most common sites for herniated disc?

• What is Sciatica?• CNS? PNS? Both?• What is the frustrating complication post

surgery?

Spinal Bifida

Pathophysiology• Neural Tube defect• Incomplete closure of

the vertebrae• 3 Levels– Spina Bifida Occulta– Meningocele– Myelomeningocele

Spinal Bifida

• Meningocele • Myelomeningocele

Spinal Bifida

Etiology• Folic acid deficiency

during pregnancy– Esp 1st month

Spinal Bifida

Diagnosis• Ultrasound• levels of fetal protein– Alpha fetoprotein

Spinal Bifida

• What food contain folic Acid?– Greens– Asparagus– Broccoli– Cauliflower– Corn– Green Beans or Peas– Sweet Potato– Cabbage or Coleslaw

– Black Beans– Lentils– Peas– Peanuts

• What deficit is associated with spina bifida?• What diagnostic test is used to detect spina

bifida invitro?• Name three foods high in folic acid.• Describe the difference between Spina

Bifida occult, meningocele and myelomeningocele.

• CNS? PNS? Both?