Neurology

Neurology

Alzheimer's Disease(and other things we need to cover)

Alzheimer’s Disease

AKA• AD• Primary degenerative

dementia• Senile dementia• Organic Brain Syndrome• Old timers disease

Pathophysiology

• Dementia– Characterized by an

uneven, downward decline in mental function

Pathophysiology

Alzheimer’s• Progressive• Irreversible• Degenerative neurologic

disease• Begins insidiously • Characterized by

– Gradual losses of cognitive function

– Disturbances in behavior & affect

Pathophysiology

• Physical changes o the cerebral cortex are visible under a microscope– Neurofibriallary tangles – Neuritic plaque– Decrease in brain size

Pathophysiology

• First affected– Cells that use Acetylcholine– Left side– Parietal & temporal lobes

Etiology

• Familial tendencies• Risk factor

– Age

• Men vs. women?– Equal

Clinical Manifestations

• Slowly progressive• Subtle• Age

– 85+


• 3 categories of Changes characteristic of dementia – – Cognitive– Functional– Behavioral


Stage 1- Early• Cognitive

– Forgetful– Subtle mild memory loss– attention span– Recent memory remote

memory


• Stage 1 – early• Functional

– Small difficulty in work (able to hide it)

– Mild anomia (cannot name objects)

– No motor deficits


Stage 1 – early• Behavioral

– Depression– Little interest in immediate

surroundings– Lack of spontaneity– Social behavior intact– Hide cognitive deficit

Stage 2 – Middle• Cognitive

– Obvious short term memory lapses

– Disoriented to time– Impaired judgment– Frequent loss of objects– Repeat the same story– Ability to think abstractly

disappears

Stage 2 – middle• Functional

– Hesitancy in verbal responses– Confabulation– Gets lost in familiar places– ability to handle money,

use phone

Stage 2 – middle• Behavior

– May try to hide memory problems

– Impulsive behavior– Hyperactive

Stage 3 – Late• Cognitive

– Disintegration of personality– Disorientation to person,

place and time– Confused– Agitation– Irritability– Paranoid delusions

Stage 3 – Late• Functional

– May forget to use objects correctly

– Dysarthria

Stage 3 – late• Behavioral

– Wandering– Restlessness– Pacing– Agitation– Disengages from activities &

relationships– Combative

Stage 3 – late• Behavioral

– Sundowning• Confused & restless after

dark• Want to go home• Less coping ability

Stage 4 – End Stage• Cognitive

– Terminal stage– Severe physical and mental

deterioration– No recognition of family or

self

Stage 4 – End stage• Functional

– Need total care for ADL’s– Incontinent– Loss of ability to

communicate– Loss of all voluntary activity– Swallowing problems

Review: Stage 1 (mild)

• Confusion and memory loss• Disorientation to time and place• Difficulty in performing routine tasks• Change in personality and judgment

Review: Stage 2 (moderate)

• Difficulty performing ADL’s• Anxiety• Suspiciousness• Agitation• Wandering• Pacing• Sleep disturbances• Difficulty recognizing family members

Review: Stage 3 (Severe)

• Loss of speech• Loss of appetite• Weight loss• Loss of B&B control• Total dependence on caregiver

Assessment & Diagnosis

• Hx & PE• Neuro tests• Autopsy• MRI

– Apparent changes

• Cognitive assessment scale

• Functional dementia scale

• Mini-Mental Status Exam– Disorientation – Cognitive impairment

Medical Management

• Exercise– anxiety & restlessness– PT

• Diet– Well balanced– Hydration

Medical Management

Rx• Cognex (tacrine Hydrochloride)

– Enhances acetylcholine uptake in the brain

– S/E/• Liver toxicity

• Aricept (donepezil)– cholinesterase inhibitor– Improves mental

function – by increasing the

amount acetylcholine

Nursing Management

Priority Nrs Dx.• Risk of injury• Anxiety• Communication• ADL• Alt. Nutrition

Nursing Management

• Sundowning– DC all non-essential meds– Check for pain– Light on– Exercise daily– No caffeine– Anti-depressants

– Having the patient sleep in a chair is better than no sleep at all

Nursing Management

Supporting Cognitive function• Calm, predictable environment• Limit environmental stimuli• Regular routine• Quiet pleasant manner of

speaking• Clear & simple explanations

Nursing Management

Supporting cognitive function

• Memory aids– Colanders– Pictures– Stop signs– Clocks– Instruction signs/notes– Pill organizer

Nursing Management

Promoting Physical safety• Move around freely• Remove hazards• Nightlights• Medications• Food• Smoking with supervision• Restraints?

– NO!

Nursing Management

Promoting Physical safety• Secure doors• Wear ID• Care at night• Shoes

• A client has been recently admitted with a medical diagnosis of dementia, Alzheimer’s type. When obtaining an assessment, the nurse should remember for safety purposes to ascertain what crucial information?

A. Sleep patterns and behaviorB. Skin turgorC. The degree of memory impairmentD. The level of distractibility

Nursing Management

Reducing anxiety & agitation• Uncluttered• Familiar• Low stimuli• Calm & hurried care• Music• Stroking• Rocking• Distraction

Nursing Management

Reducing anxiety• Validation therapy

– Enter their reality– Ask questions– Feelings – Distract

• Reality orientation• Structure activities• Avoid triggers

Nursing Management

Improving communication• Unhurried• noise• distractions• Clear & easy• List• Simple written • Non-verbal

Nursing Management

Promoting independence• Highest level of function• Clothing• Simple steps• Personal dignity• Choices• Dangerous activities

Nursing Management

Promoting Socialization & intimacy

• Visits Good– Short– Non-stress– 1 or 2 at a time

• Simple activities• Walking

Nursing Management

• Exercise• Pet therapy• Intimacy????

Nursing Management

Adequate nutrition• Calm & simple• Familiar foods• Look appetizing• Taste good• 1 food at a time• Small pieces

Nursing Management

• Finger foods• Food on the run• Watch hot food• Bibs?• Dental care

Nursing Management

Balance activity and Rest• Wandering• Assess sleep pattern• Day time

– Exercise– Regular patterns– Limit long naps

Nursing Management

• Sleep aid– Warm milk– Music– Back rub– Warm bath– Tea

Complications

• Malnutrition• Dehydration• Pneumonia• Pain

– Grimacing– Restlessness– Flexed position

Small Group Questions

• Damage to the brain in a patient with Alzheimer’s Disease occurs where?

• What memory is lost first in a patient with Alzheimer’s disease?

• Which neurotransmitter is associated with memory

• Given three nursing intervention for a patient with Alzheimer’s who is losing weight?

• A patient is confused and wandering. What intervention will best maintain safety?

• What about night time wandering?• A patient with Alzheimer’s occasionally she screams and

moans and annoys the other patients by repeating the same word over and over. The best approach for a solution to this behavior is for the nurses to do what?

• What medications are being used to treat AD?

• What activities are good for a patient who is confused or has short attention span?

• What are the priority nursing diagnosis for someone with AD?

• Give an example of confabulation• What is the biggest risk factor for AD?• When are AD patient most agitated?

Strategies to Minimize or Prevent Sundowning

• Make sure sundowning is not the result of physical illness or medication. • Caregivers need to be flexible in their approach and in their

expectations. • Avoid caffeine drinks in the afternoon and evening. • Have non-glare lighting. • Be soothing and try to be undemanding. Try to make the person with

Alzheimer's feel safe and secure.

• Make sure the person's physical needs are met, i.e. that they are not hungry, thirsty, or constipated.

• Avoid too many naps during the day. • Soothing music may help relax them. • Provide stimulating activities in the day without exhausting

the person. • Remember that a person with Alzheimer's does not have

control over their behavior

A 93 year-old female with a history of Alzheimer’s Disease gets admitted to an Alzheimer’s unit. The patient has exhibited signs of increased confusion and limited stability with gait. Moreover, the patient is refusing to use a w/c. Which of the following is the most appropriate course of action for the nurse?

A. Recommend the patient remain in her room at all times. B. Recommend family members bring pictures to the

patient’s room. C. Recommend a speech therapy consult to the doctor. D. Recommend the patient attempt to walk pushing the w/c

for safety.

• Fill in the blanks of the statement with the appropriate terms regarding the pathophysiology of a patient who has Alzheimer's disease: Researchers have identified two microscopic changes, ____ & ____, that occur in the brain of a patient with Alzheimer’s disease. These changes result in cortical atrophy.

A.Neuritic plaquesB.Neurofibrillay tanglesC. Nerve demyelinationD.Sclerotic plaquesE. Dysplasia

Cerebral Palsy

Pathophysiology• Non progressive• D/T cerebral anoxia

during birth• Results in CNS damage• No Cure!

Poliomyelitis

Pathophysiology• Virus• Mode of transmission

– Fecal-oral

Poliomyelitis

Clinical Manifestations• Cold-like symptoms• Pain & stiffness

– Back– Neck– Legs– Bulbar paralysis

Poliomyelitis

Prevention• VACCINE

– IPV• Inactive Polio Vaccine• Killed virus• Salk vaccine

– OPV• Oral polio Vaccine• Live vaccine• Can cause polio in some• Not used in USA

Poliomyelitis

Vaccination schedule• 2 months• 4 months• 6-18 months• Booster 4-6 years

The nurse is preparing to discharge a client with a long history of polio. The nurse should tell the client that:

A.Taking a hot bath will decrease stiffness and spasticity.

B.A schedule of strenuous exercise will improve muscle strength.

C. Rest periods should be scheduled throughout the day.

D.Visual disturbances can be corrected with prescription glasses.

Neurosyphilis

Pathophysiology• Bacteria• Mode of transmission

– STD

• Mucus membrane • Systemic • Lymph • Brain & Spinal cord

Neurosyphilis

• Tabes dorsalis =– posterior nerve root

involvement– Paralysis

• Seizures• H/A• Hemiparesis

Neurosyphilis

Treatment• Antibiotics• Both partners• Infants

Varicella / Herpes Zoster

Pathophysiology• Virus• Mode of transmission

– Airborne– Contact

• Incubation period – 2 weeks


Pathophysiology• Exposure • Prodromal stage

– General malaise– No rash– Contagious!


• Rash stage– CHICKEN POX’s– Vesicular & pustular– Spread rapidly– New lesions for 2-3 days


• Scab stage– Lesion begin to dry– No new lesion– lesions crusted

• Not contagious


• Dormant stage– Virus retreats– Dormant– Dorsal horn of the spinal

cord


• Reactivated– Later!!!!

• Stress• Decreased immune

system

– Reactivated– Along peripheral nerve– Shingles


S&S of shingles• Tingling• Itching• Pain• Rash

– Red bumps– Blisters


• Prevention– Varicella vaccine– (85% effective)

• Treatment– Self-limiting– Anti-viral meds– NO aspirin

• Reye syndrome• Liver failure

Question

• An adult who has never had chicken pox’s or the varicella vaccine and is exposed to a child with chicken pox, is at risk of developing what?

A. Chicken pox’sB. ShinglesC. Nothing, varicella only affects children

Question

• An adult who has never had chicken pox’s or the varicella vaccine is exposed to an adult with shingles. What is the adult at risk of developing?

A. Chicken pox’sB. ShinglesC. Syphilis

Question

• An adult who had chicken pox’s as a child is exposed to an adult with shingles. What is the adult at risk of developing?

A. Chicken pox’sB. ShinglesC. Nothing

Question

• What must happen before a person can develop shingles?

A. They must be a door mat B. They must go to sleep C. They must have cancerD. They must have chicken pox’sE. They must have spinal cord injury

Question

• Which of the following can lead to an outbreak in shingles (of a patient with dormant herpes Zoster)

A. StressB. CancerC. Immunosuppressant medicationD. Exposure to a person with chicken pox’sE. Exposure to a person with shingles

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