MEDICAL SURGICAL NURSING

Caring for Clients With Neurologic and Spinal Cord Disorders

Dr Ibraheem Bashayreh, RN, PhD

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EPILEPSY DEFINITION A chronic neurologic disorder manifesting by repeated

epileptic seizures (attacks or fits) which result from paroxysmal uncontrolled discharges of neurons within the central nervous system (grey matter disease).

The clinical manifestations range from a major motor convulsion to a brief period of lack of awareness. The stereotyped and uncontrollable nature of the attacks is characteristic of epilepsy.

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PATHOGENESIS The 19th century neurologist Hughlings Jackson

suggested “a sudden excessive disorderly discharge of cerebral neurons“ as the causation of epileptic seizures.

Recent studies in animal models of focal epilepsy suggest a central role for the excitatory neurotransmiter glutamate (increased in epi) and inhibitory gamma amino butyric acid (GABA) (decreased)

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EPIDEMIOLOGY AND COURSE Epilepsy usually presents in childhood or adolescence but may

occur for the first time at any age.

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EPILEPSY

is a symptom of numerous disorders, but in the majority ofsufferers the cause remains unclear despite careful historytaking,examination and investigation!

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EPILEPSY & SEIZURES Epilepsy is a neurological disorder characterized by

recurring seizures also known as a “seizure disorder”

A seizure is a brief, temporary disturbance in the electrical activity of the brain

6A seizure is a symptom of epilepsy

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THE BRAIN IS THE SOURCE OF EPILEPSY

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• All brain functions -- including feeling, seeing, thinking, and moving muscles -- depend on electrical signals passed between nerve cells in the brain

• A seizure occurs when too many nerve cells in the brain “fire” too quickly causing an “electrical storm”

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EPILEPSY - CLASSIFICATIONThe modern classification of the epilepsies

is based upon the nature of the seizures rather than the presence or absence of an underlying cause.

Seizures which begin focally from a single location within one hemisphere are thus distinguished from those of a generalised nature which probably commence in a deeper structures (brainstem? thalami) and project to both hemispheres simultaneously.

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EPILEPSY - CLASSIFICATION Focal seizures – account for

80% of adult epilepsies- Simple partial seizures- Complex partial seizures- Partial seizures secondarilly

generalised

Generalised seizures

Unclassified seizures

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CLASSIFYING EPILEPSY AND SEIZURES

Classifying epilepsy involves more than just seizure type Seizure types:

Partial GeneralizedSimple Complex Absence Convulsive

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Consciousnessis maintained

Consciousnessis lost or impaired

Altered awareness Characterized bymuscle contractionswith or without lossof consciousness

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GROUPS AT INCREASED RISK FOR EPILEPSY About 1% of the general population develops epilepsy The risk is higher in people with certain medical

conditions: Mental retardation Cerebral palsy Alzheimer’s disease Stroke Autism

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WHAT CAUSES EPILEPSY?

In about 70% of people with epilepsy, the cause is not known

In the remaining 30%, the most common causes are: Head trauma Infection of brain tissue Brain tumor and stroke Heredity Lead poisoning Prenatal disturbance brain development

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SYMPTOMS THAT MAY INDICATE A SEIZURE DISORDER Periods of blackout or confused memory Occasional “fainting spells” Episodes of blank staring in children Sudden falls for no apparent reason Episodes of blinking or chewing at inappropriate

times A convulsion, with or without fever Clusters of swift jerking movements in babies

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SEIZURE TRIGGERS Missed medication (#1 reason) Stress/anxiety Hormonal changes Dehydration Lack of sleep/extreme fatigue Photosensitivity Drug/alcohol use; drug interactions

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HOW IS EPILEPSY DIAGNOSED? Clinical Assessment

Patient historyTests (blood, EEG, CT, MRI or PET scans)Neurologic exam

ID of seizure type Clinical evaluation

to look for causes

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EPILEPSY DIFFERENTIAL DIAGNOSISThe following should be considered in the diff. dg.

of epilepsy: Syncope attacks Cardiac arrythmias Migraine Hypoglycemia – seizures or intermittent

behavioral disturbances may occur. Narcolepsy – inappropriate sudden sleep

episodes Panic attacks PSEUDOSEIZURES – psychosomatic and

personality disorders

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EPILEPSY – INVESTIGATION The concern of the clinician is that epilepsy may

be symptomatic of a treatable cerebral lesion. Routine investigation: Haematology,

biochemistry (electrolytes, urea and calcium), chest X-ray, electroencephalogram (EEG).Neuroimaging (CT/MRI) should be performed in all persons aged 25 or more presenting with first seizure and in those pts. with focal epilepsy irrespective of age.

Specialised neurophysiological investigations: Sleep deprived EEG, video-EEG monitoring.

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TYPES OF TREATMENT Medication Surgery Nonpharmacologic treatment

Ketogenic diet: a high-fat, adequate-protein, low-carbohydrate diet primarily used to treat difficult-to-control (refractory) epilepsy in children

Vagus nerve stimulationLifestyle modifications

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EPILEPSY - TREATMENT The majority of pts respond to drug therapy

(anticonvulsants). In intractable cases surgery may be necessary. The treatment target is seizure-freedom and improvement in quality of life!

Basic rules for drug treatment: Drug treatment should be simple, preferably using one anticonvulsant (monotherapy). “Start low, increase slow“. Polytherapy is to be avoided especially as drug interactions occur between major anticonvulsants.

The commonest drugs used in clinical practice are: Carbamazepine, Sodium valproate, Phenytoin (first line drugs) Lamotrigine, Topiramate, Levetiracetam, Pregabaline (new anti-epileptic drugs AEDs)

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EPILEPSY – TREATMENT (CONT.)If pt is seizure-free for three years,

withdrawal of pharmacotherapy should be considered. Withdrawal should be carried out only if pt is satisfied that a further attack would not ruin employment etc. (e.g. driving licence). It should be performed very carefully and slowly! 20% of pts will suffer a further sz within 2 yrs.

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EPILEPSY – SURGICAL TREATMENT A proportion of the pts with intractable epilepsy

will benefit from surgery. Epilepsy surgery procedures: Curative (removal

of epileptic focus) and palliative (seizure-related risk decrease and improvement of the QOL)

Curative (resective) procedures: Anteromesial temporal resection, selective amygdalohippocampectomy, extensive lesionectomy, cortical resection, hemispherectomy.

Palliative procedures: Corpus callosotomy and Vagal nerve stimulation (VNS).

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STATUS EPILEPTICUS A condition when consciousness does not return between seizures for more than 30 min. This state may be life-threatening with the development of pyrexia, deepening coma and circullatory collapse. Death occurs in 5-10%. Status epilepticus may occur with frontal lobe lesions (incl. strokes), following head injury, on reducing drug therapy, with alcohol withdrawal, drug intoxication, metabolic disturbances or pregnancy. Treatment: AEDs intravenously ASAP, event. general anesthesia with propofol or thipentone should be commenced immediately.

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POTENTIALLY DANGEROUS RESPONSES TO SEIZURE

DO NOT Put anything in the person’s mouth Try to hold down or restrain the person Attempt to give oral anti-seizure medication Keep the person on their back face up

throughout convulsion

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MULTIPLE SCLEROSIS

is an inflammatory disease in which the fatty myelin sheaths around the axons of the brain and spinal cord are damaged, leading to demyelination and scarring as well as a broad spectrum of signs and symptom

High risk groups Caucasian females Ages: 20–40 Family history Cold, wet, northern U.S.

MULTIPLE SCLEROSIS Pathophysiology

Autoimmune response with viral trigger Demyelination

Spinal cord Brain Nerves of the CNS

Myelin replaced with plaque Impulse transmission interrupted/ halted

MULTIPLE SCLEROSIS (MS) Manifestations

Exacerbations: Symptoms usually appear in episodic acute periods of worsening

and remissions: is characterized by unpredictable relapses followed by periods of months to years of relative quiet (remission) with no new signs of disease activity. Progression longer exacerbations

Triggers for exacerbations Heat Sun Infections Stress

MULTISYSTEM EFFECTS OF MULTIPLE SCLEROSIS.

MULTIPLE SCLEROSIS Long-Term Consequences

Urinary tract infections Pressure ulcers/joint contractures Falls Pneumonia Depression

MULTIPLE SCLEROSIS - MEDICATIONS Medications

Immunomodulators Monoclonal antibody :are monospecific

antibodies that are the same because they are made by identical immune cells that are all clones of a unique parent cell.

Steroids Antispasmotics Urinary agents Pharmacotherapy for fatigue

MULTIPLE SCLEROSIS – INTERDISCIPLINARY CARE Other Therapies

Physical therapy Surgical intervention

Neurectomy: is the surgical removal of a nerve or a section of a nerve

Rhizotomy: is a neurosurgical procedure that selectively severs problematic nerve roots in the spinal cord, most often to relieve the symptoms of neuromuscular conditions.

Plasmapheresis: is a blood purification procedure used to treat several autoimmune diseases

Nutritional support

MULTIPLE SCLEROSIS – CLIENT TEACHING Client/Family Teaching

Triggers for exacerbations/stressors Medications/side effects Coping with deficits Counseling/support groups

MULTIPLE SCLEROSIS – NURSING CARE Assessment

Motor assessment Muscle strength; chewing/swallowing

Sensory changes Tingling; vision changes

Mood changes Urinary elimination patterns Past medical/family history

MULTIPLE SCLEROSIS – NURSING CARE Assessment

Respiratory effort ADLs Appearance

MULTIPLE SCLEROSIS – NURSING CARE Nursing Diagnoses

Fatigue Self-Care Deficit Ineffective Coping Impaired Mobility Risk for Injury

MULTIPLE SCLEROSIS – NURSING CARE Evaluation

ADL Coping Knowledge level

Medications Diet Complications

PARKINSON’S DISEASE Most common neurologic disorder in the U.S. 1.5 million affected Most common over age 40 Caucasian men vs. women

PARKINSON’S DISEASE Pathophysiology

Deficiency of dopamine Atrophy of cerebral cortex neurons Decreased dopamine receptors

Loss of inhibition of acetylcholine Constant excitement of motor neurons

PARKINSON’S DISEASE Manifestations of Parkinson’s

Cardinal signs Tremor Rigidity Bradykinesia

Tremor Rigidity of neck, shoulders, and trunk Bradykinesia: is characterized by slowness of

movement Drooling : saliva flows outside the mouth

PARKINSON’S DISEASE - MEDICATIONS Medications

Dopaminergics Dopamine agonists Anticholinergics MAOIs

PARKINSON’S DISEASE – INTERDISCIPLINARY CARE Other Therapies

Surgery Pallidotomy: is a procedure where a tiny electrical

probe is placed in the globus pallidus (one of the basal ganglia of the brain), which is then heated to to 80 degrees celsius for 60 s, to destroy a small area of brain cells

Stereotactic thalamotomy: is an invasive procedure, primarily effective for tremors such as those associated with Parkinson's Disease (PD), where a selected portion of the thalamus is surgically destroyed (ablated).

Deep brain electrical stimulation Complementary therapy

Yoga Massage Acupuncture

PARKINSON’S DISEASE – CLIENT TEACHING Client/Family Teaching

Assistive devices Communication techniques Decreasing aspiration risk Safety Diet Exercise

PARKINSON’S DISEASE – NURSING CARE Assessment

Cognition, mood Motor functioning

Falls; stiffness; jerking movements “Pill-rolling”: A circular movement or tremor of the

tips of the thumb and the index finger when brought together.

Facial muscle effects Weight loss; chewing/swallowing

PARKINSON’S DISEASE – NURSING CARE Diagnoses

Impaired Physical Mobility Impaired Verbal Communication Imbalanced Nutrition: Less than Body

Requirements

PARKINSON’S DISEASE – NURSING CARE Evaluation

Ability to: Ambulate Chew and swallow Communicate

Complications Knowledge level related to disease process

MYASTHENIA GRAVIS is an autoimmune neuromuscular disease

leading to fluctuating muscle weakness and fatigability.

Women ages 20–30 Exacerbations and remissions Triggers for exacerbations

MYASTHENIA GRAVIS Pathophysiology

Auto-antibodies from thymus gland Block acetylcholine receptors Decrease number of receptors Blockage of nerve impulses

Face, lips, tongue, neck, and throat Can affect fine motor skills Can affect respiratory muscles

MYASTHENIA GRAVIS Manifestations

Ptosis (is a drooping of the upper or lower eyelid); diplopia (double vision)

Slurred speech Difficulty chewing and swallowing Respiratory insufficiency Fatigue Altered facial expressions Difficulty writing

MYASTHENIA GRAVIS Life-Threatening Complications

Cholinergic crisis: is an over-stimulation at a neuromuscular junction due to an excess of acetylcholine (ACh), as of a result of the inactivity (perhaps even inhibition) of the AChE enzyme, which normally breaks down acetylcholine

Severe muscle weakness, nausea, vomiting Salivation, sweating, bradycardia Myasthenia crisis: is a life-threatening condition, which is

defined as weakness from acquired myasthenia gravis (MG) that is severe enough to necessitate intubation or to delay extubation following surgery . The respiratory failure is due to weakness of respiratory muscles.

Muscle weakness Inability to swallow; respiratory distress

MYASTHENIA GRAVIS - MEDICATIONS Medications

Anticholinesterase medications Steroids Cytotoxic agents

MYASTHENIA GRAVIS – INTERDISCIPLINARY CARE Short-Term Treatments

Thymectomy Removal of the thymus Decreased auto-antibody production

Plasmapheresis Removes auto-antibodies

MYASTHENIA GRAVIS – CLIENT TEACHING Client/Family Teaching

Medication regimen Strict time schedule Side effects

CPR: airway management Symptoms of myasthenia and cholinergic crisis

MYASTHENIA GRAVIS – NURSING CARE Assessment

Muscle weakness Respiratory effort Ability to swallow Speech Vision

SPINAL CORD INJURY – NURSING CARE Assessment

Respiratory Rate, depth, effort Breath sounds

Sensory level Elimination History of the trauma

SPINAL CORD INJURY – NURSING CARE Diagnoses

Ineffective Breathing Pattern Impaired Physical Mobility Impaired Urinary Elimination/Constipation Situational Low Self-Esteem

SPINAL CORD INJURIES Affect adolescent and adult males Motor vehicle crashes Falls Violent acts

Shootings Sports injuries

SPINAL CORD INJURIES Pathophysiology

Bruising or compression of cord via injury Bleeding into gray matter Inflammatory response

Edema Hypoxia Ischemia

No regeneration

SPINAL CORD INJURIES Classifications

Level of injury Cervical—tetraplegia: also known as quadriplegia,

is paralysis caused by illness or injury to a human that results in the partial or total loss of use of all their limbs.

Thoracic—paraplegia: is an impairment in motor or sensory function of the lower extremities

Sacral Amount of cord damage

Complete Incomplete

SPINAL CORD INJURY Complications

Decubitus (pressure) ulcers Pain, hypotonia, autonomic dysreflexia Spinal shock, orthostatic hypotension,

bradycardia, deep vein thrombosis Limited chest expansion, pneumonia

autonomic dysreflexia: is a potentially life threatening condition which can be considered a medical emergency requiring immediate attention. AD occurs most often in spinal cord-injured individuals with spinal lesions above the (T6) spinal cord level. Acute AD is a reaction of the autonomic (involuntary) nervous system to overstimulation. It is characterised by severe paroxysmal hypertension (episodic high blood pressure) associated with throbbing headaches, profuse sweating, nasal stuffiness, flushing of the skin above the level of the lesion, bradycardia, apprehension and anxiety, which is sometimes accompanied by cognitive impairment

SPINAL CORD INJURY Complications

Stress ulcers, paralytic ileus, stool impaction, stool incontinence

Urinary retention, urinary incontinence, neurogenic bladder, urinary tract infections, impotence, decreased vaginal lubrication

Joint contractures, muscle spasms, muscle atrophy, pathologic fractures, hypercalcemia

SPINAL CORD INJURY Special complications

Spinal shock: 30–60 minutes post injury Loss of reflex activity below injury Bradycardia and hypotension Loss of sweating and temp control Bowel and bladder dysfunction Flaccid paralysis

SPINAL CORD INJURY Special Complications

Autonomic dysreflexia Exaggerated sympathetic response SCIs T6 or above

Involves triggers/stimuli Medical emergency

CERVICAL SPINAL CORD INJURIES C1, C2, C3 no movement or sensation below

the neck Ventilator-dependent

C4 movement and sensation of head and neck; some partial function of the diaphragm

CERVICAL SPINAL CORD INJURIES C5 controls head, neck, and shoulders; flexes

elbows C6 uses shoulder, extends wrist. C7–C8 extends elbow, flexes wrist, some use

of fingers

THORACIC AND SACRAL SPINAL CORD INJURIES T1–T5 has full hand and finger control, full

use of thoracic muscles T6–T10 controls abdominal muscles, has

good balance

THORACIC AND SACRAL SPINAL CORD INJURIES T11–L5 flexes and abducts the hips; flexes

and extends the knees S1–S5 full control of legs; progressive bowel,

bladder, and sexual function

SPINAL CORD INJURY – INTERDISCIPLINARY CARE Emergent Care

Airway, breathing circulation Pain; sensation Immobilization: neck, spine Oxygenation needs Intravenous fluids

SPINAL CORD INJURY – INTERDISCIPLINARY CARE Diagnostic testing

Cervical spine x-rays CT scan MRI

SPINAL CORD INJURY – INTERDISCIPLINARY CARE Pharmacotherapy

Corticosteroids Histamine blockers Anticoagulants Stool softeners

SPINAL CORD INJURY – INTERDISCIPLINARY CARE Stabilization/immobilization

Braces Body casts Cervical tongs/traction Halo vest

SPINAL CORD INJURY – INTERDISCIPLINARY CARE Surgical interventions

Spinal fusion Decompression laminectomy Insertion of rods

HERNIATED DISK – INTERDISCIPLINARY CARE Treatment Medications for pain, muscle spasm; oral or

injected corticosteroids Conservative treatment (body mechanics,

exercises, firm mattress, warm moist compresses)

Surgery: diskectomy, laminectomy, spinal fusion, microdiskectomy

SPINAL CORD INJURY – NURSING CARE Assessment

Respiratory Rate, depth, effort Breath sounds

Sensory level Elimination History of the trauma

SPINAL CORD INJURY – NURSING CARE Diagnoses

Ineffective Breathing Pattern Impaired Physical Mobility Impaired Urinary Elimination/Constipation Situational Low Self-Esteem

SPINAL CORD INJURY – NURSING CARE Evaluation

Gas exchange/respiratory functioning Ability to manage ADL Bowel and bladder function Skin integrity Absence of system based complications

TRIGEMINAL NEURALGIA Two sensory branches of the trigeminal

nerve Pain along branches No known cause

Dental procedure/surgery Facial trauma Infection Tumor

TRIGEMINAL NEURALGIA Manifestations of Trigeminal Neuralgia

Severe one-sided facial pain Stabbing/burning: forehead, nose, lips, cheek Exacerbations and remissions Simple actions can trigger symptoms

TRIGEMINAL NEURALGIA - MEDICATIONS

Medications Anticonvulsant carbamazepine Phenytoin Baclofen