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Chapter 43: Central and Peripheral Nervous System Disorders

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Increased Intracranial Pressure (pg. 666) The cranium consists of 1. Brain tissue 2. Blood 3. Cerebrospinal fluid (CSF) If one or more of these increases significantly without a decrease in one or the other two, ICP becomes elevated.

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Increased Intracranial pressure The skull cannot expand so a tumor, cerebral edema, brain abscess, or bleeding compresses the brain and causes increased intracranial pressure (ICP) As pressure increases, the cerebral blood flow decreases and PCO2 increases causing cerebral edema which increases the ICP even more

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Increased Intracranial Pressure If not recognized, the brainstem will herniate thru the foramen magnum brainstem controls vital signs so death will occur

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ICP Signs and symptoms develop rapidly or slowly If slow it may be over looked Keep check on baseline and observe closely change in LOC is usually earliest sign alterations may be difficult to determine

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Level Of Consciousness Confusion, restlessness, disorientation and drowsiness may or may not be a symptom of impending change in LOC Report sudden change to Dr stat Change in LOC is one of the earliest signs of ICP

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Headache Pain is usually intermittent--if constant condition usually grave coughing, sneezing, straining at stool increases headache lying in bed with head elevated reduces ICP and headache

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Vomiting and ICP Commonly occurs without warning of nausea and without a relationship to eating projectile in nature

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Papilledema Papilledema (edema of optic nerve caused by obstruction of venous drainage due to ICP Can be seen only with an ophthalmoscope Affects pupillary response to light. Normal pupil response to strong light is rapid constriction. In IICP the response is sluggish or nonexistent (fixed)

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Posturing Decorticate--arms flexed--problem with cervical spinal tract or cerebral hemisphere Decerebrate--arms extended (more serious as brainstem damage, problems within midbrain or pons see page 660 for picture

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Symptoms of ICP Change in LOC headache vomiting papilledema vital signs--temp rises, b/p rises and pulse pressure widens pupils sluggish or fixed decorticate or decerebrate position

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Vital signs Temp rises, B/P rises and pulse pressure widens. These 3 s/s are called Cushing’s triad. A late sign in IICP. Pulse may increase at first but later becomes slow (40-60) and bounding resp rate is irregular or cheyne-stokes (shallow, rapid, then decreases and then apnea)

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Medical and surgical management Osmotic diuretics (mannitol, glycerol); steroids to reduce cerebral edema If clot then it is removed; surgery for depressed skull fx, tumor or bleeding…fix the cause stat

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Medical & surgical management Restrict fluids, lumbar punctures to remove CSF and hyperventilation via ventilator to cause resp alkalosis which constricts cerebral arteries and reduces ICP

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Medical Management May order: insertion of foley NG tube for gastric decompression or feedings Stool softener to prevent straining Histamine antagonist (Pepcid) to prevent stress ulcers Cooling blankets if hyperthermia

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Normal ICP In the Ventricles Norm: 1 to 15 Moderate : 15 to 40 High:  40 mm Hg Although the ICP varies, a rise of 2 mm HG from a previous measurement is cause for concern.

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Nursing care ICP Teach to remain quiet in bed and not to turn in bed without help avoid ROM until ICP normal and Dr orders suction only when absolutely necessary…gently remove secretions with gauze give oxygen before suctioning

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Nursing Care ICP ICP can affect temp regulation so cooling blanket may be needed Neuro assessment should be done q 30 min Avoid extreme flexion of hip because this increases intraabdominal, ICP and intrathoracic pressure

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Nursing Care ICP A neurologic flow sheet that includes the Glasgow Coma Scale or Ranchos Los Amigos Scale and ICP pressure measurement (see chapter 42) is used to establish a data base and record Intake and output and daily weights are recorded to monitor the fluid and nutritional status of the client.

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Nursing Care ICP Laboratory findings such as serum electrolyte levels and arterial blood gas measurements are analyzed to detect fluid, electrolyte, and acid-base complications, or to evaluate the effectiveness of medical management. Bowel sounds are present in all quad’s and palpated to determine if there is distention. Bowel elimination patterns are monitored.

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Nursing Care ICP Keep head straight and head of bed slightly elevated If a basal skull fx and ICP may be kept flat but in no case must the head be allowed to be lower than body Reduce noise and bright lights, limit movement, space activity

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Activities That increase ICP Coughing range of motion exercises sneezing hip flexion of 90 degrees or greater vomiting suctioning

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Activities that increase ICP Straining to have a BM (valsalva maneuver holding breath digging heels into bed to help in repositioning turning in bed without help

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Nursing Care ICP Hourly I&O may be done If steroids given, monitor glucose as ordered test stools for blood assess bowel and bladder elimination and prevent straining complete care given until ICP normal monitor temp q 4 hours & prn

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Nursing Care ICP Monitor I&O…fluids may be restricted to reduce cerebral edema and prevent vomiting and coughing which raise pressures calculate IV fluids so given over 24 hours nutrition may be total parenteral nutrition (TPN) assess skin turgor and electrolytes

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Infectious & Inflammatory Disorders Meningitis Encephalitis Gullian-Barre Syndrome Poliolmyelitis Brain Abscess

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Meningitis (Covering of the Brain) pg 669 Inflammation of meninges (three membranes that cover the brain-dura, arachnoid, & pia mater) May affect cerebral cortex and decrease blood flow to the brain Meningococcus, strept, staph and pneumococcus most common cause (contagious—meningococcal) Reaches brain by the bloodstream or ear or sinus infection

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Meningitis Most adults with bacterial meningitis recover without permanent neurologic damage or dysfunction. When complications do occur, they usually are serious.

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Meningitis S/S Fever, nuchal rigidity (pain and stiffness of neck); inability to place chin on chest nausea and vomiting, photophobia, headache, restlessness, irritability and seizures severe may cause opisthotonus (arching of back and neck hyperextended

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Kernig’s Sign Positive Kernig’s sign ( inability to extend the leg when the thigh is flexed on abdomen

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Brudzinsi’s Sign Brudzinski’s sign--flexion of neck produces flexion of knees and hips

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Diagnostic findings: Meningitis Lumbar puncture done if bacterial meningitis the CSF is cloudy and pressure is elevated, glucose is decreased, protein is elevated and WBC & RBCs are elevated Cultures are done If culture negative then it is viral in nature

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Medical Management IV fluids, antibiotics, anticonvulsants are used to treat sulfonamide given to people who are exposed observe for altered LOC, signs of airway obstruction and cardiac arrhythmias

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Encephalitis (Brain Inflammation) pg 676 Infectious disease of CNS characterized by changes in both white and gray matter of spinal cord and brain Extensive nerve cell destruction may occur

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Encephalitis (brain inflammation) Symptoms similar to meningitis Caused by bacteria, fungi, or virus cause virus: Polio, herpes, measles, mumps, chickenpox, mono, hepatitis,,St. Louis virus and Eastern and Western equine virus

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Encephalitis occurs after a viral infection elsewhere (measles or vaccinations) Poisoning by drugs and chemicals, such as lead, arsenic, or Carbon monoxide, may closely resemble encephalitis clinically!!!

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Encephalitis Onset of viral is sudden with fever, severe headache, stiff neck, vomiting and drowsiness lethargy is a prominent symptom and coma and delirium may occur Tremors, seizures, spastic or flaccid paralysis, irritability

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Encephalitis Muscle weakness, incoordination, incontinence and visual disturbances (photophobia, involuntary eye movement, double or blurred vision may occur speech changed, increased ICP and shock

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Encephalitis--brain inflammation Lumbar puncture done…CSF pressure elevated but fluid clear EEG has slow wave forms treatment supportive only as viral Total care, LOC, vital signs monitored

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Encephalitis Mild cases are common and may go unrecognized complications and deaths are more common in infants and elderly usually recover in 2-3 weeks unless severe

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Guillain-Barre’ syndrome Pg.677 Rare, inflammatory condition involving the CNS that causes rapid weakness and loss of sensation. History of recent infection (esp. resp tract); recent surgery or vaccinations also seen in malignancy and Lupus. The affected nerves become inflamed and edematous. Mild to severe ascending muscle weakness or paralysis develops.

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Guillain-Barre’ Syndrome May be autoimmune response to viral infection Takes approx 1 month to start improving and may take 1 year or longer to recover Muscle weakness or paralysis can occur and be permanent. Immobility complications kills (pneumonia & infection)

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Guillain Barre’ Syndrome Weakness, tingling, and numbness in arms and legs may be 1st symptoms Weakness usually starts in legs and moves to arms and face may affect the muscle of respiration Muscle weakness may be followed by paralysis. chewing, talking, and swallowing become difficult if cranial nerves involved

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Medical Management Guillian Barre’ Plasmaphoresis removal of plasma from the blood and reinfusion of the cellular components with saline, has been shown to shorten the course of the DX. If performed within the first 2 weeks. If the respiratory muscles are involve, endotracheal intubation & mechanical ventilation become necessary. Difficulty chewing—may need IV fluids, gastric feedings, or TPN

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Nursing Management Monitory respiratory status/distress Use IS R/T incapacitated by immobility, provide meticulous skin care and change position every 2 hours. Give passive ROM q 2 hours

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Brain abscess Pg. 678 A collection of pus caused by a bacterial infection in the brain—if untreated it can be fatal!! Causes: infection that spreads from an infected skull (osteomyelitis, mastoiditis, sinusitis) infection spreads thru bloodstream or trauma

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Brain abscess May occur from infection of teeth, sinus, middle ear, or from an infection in other organs. common after endocarditis, pulmonary or abdominal infection, or intracranial surgery fever, headache,  IICP s/s, seizures, muscle weakness, paralysis and lethargy

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Brain abscess Risk increases with head injury, illness that lowers resistance (esp. diabetes) recent infection (esp around eye, nose, or face) Iv drug users and immuno-suppressed

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Brain abscess I&O fluids may be restricted as over-hydration may cause cerebral edema antibiotics usually given 4 to 6 weeks; craniotomy may be needed seizure precautions; pad side rails, decrease stimuli

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General Nursing Care for Inflammatory Disorders Swallowing may be affected---give PO drugs slowly…no narcotics REPORT sudden increase in headache Dr. must order ROM but turn and give skin care….cooling blanket may be needed for temp

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Nursing Care for Inflammatory Disorders Monitor vitals…complete care neuro checks…use Glasgow Coma scale Seizure precautions—insert a padded tongue blade in the mouth ONLY IF THE TEETH ARE NOT TIGHTLY SHUT!! lung sounds and suction PRN******caution it raises ICP elevate head of bed 30 degrees keep oral airway at bedside

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Neuromuscular disorders PG 678 Involves the nervous system and indirectly affects the muscles Multiple Sclerosis Myasthenia Gravis Amyotrophic lateral sclerosis (Lou Gehrig)

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Multiple sclerosis PG 678 Chronic, progressive disease of the peripheral nerves. Onset in young adult and early middle life (20 to 40) May be autoimmune people in colder climates at higher risk

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Multiple sclerosis Permanent degeneration as patchy destruction of myelin sheath of nerve fibers of brain and spinal cord Impulses cannot go thru without myelin so muscles become paralyzed scar tissue replaces myelin (sclerotic)

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Multiple sclerosis Myelin sheath swells (exacerbation) when it is deteriorating when swelling goes down then there is a remission may go for years without symptoms each exacerbation causes the symptoms to last longer and more severe

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Multiple sclerosis Weakness of arms and legs may progress to paraplegia may be incontinent visual disturbances may eventually progress to blindness infection and emotional upsets may cause exacerbations NO CURE

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Multiple sclerosis Intellectual functioning may be impaired late in disease loss of memory, impaired judgment shallow breathing can cause pneumonia (most common cause of death) may live 20 years with the disease

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Drugs for MS Lioresal and Dantrium--muscle spasticity and rigidity Antibiotics, urinary infectives, tranquilizers for mood swings Ditropan---urinary incontinence Urecholine for retention Steroids

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Nursing Sensory impairment: be careful with hot, cold, avoid injury REST, conserve energy Polyunsaturated fate, linoleic acid--found in sunflower oil may help

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Myasthenia Gravis pg 681 Disorder of muscles, with increasing fatigue and weakness as muscles are used Fatigue appears to be caused by a defect in nerve impulses from nerve endings to muscles Receptor sites destroyed Thought to be autoimmunne

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Myasthenia Gravis Most common symptoms are ptosis of eyelids, difficulty chewing and swallowing, diplopia, voice weakness, masklike facial expressions and weakness of arms and legs May affect respirations

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Myasthenia Gravis Diagnosed by giving IV Tensilon which relieves symptoms in a few seconds if it is Myasthenia Chest x-ray may show tumor of thymus

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Myasthenia gravis Treatment is Mesitonon or Myelelase Atropine is antidote for mestinon and other anticholinesterase drugs Thymus gland may be surgically removed as it may cause destruction of nerve endings

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Mestinon or Mytelase Observe for drug overdose….abdominal cramps, clenched jaws, muscle rigidity Give drug at exact intervals to maintain therapeutic blood levels Watch for resp distress if drugs not affective May aspirate as cannot swallow

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Amyotrophic Lateral Sclerosis--Lou Gehrig’s Disease 682 Progressive, fatal neuro disorder of unknown cause Degeneration of motor neurons of CNS which causes wasting and weakness of muscles Fasciculations (twitching) and difficulty speaking or swallowing

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Amyotrophic Lateral Sclerosis--Lou Gehrig’s Disease 682 Periods of inappropriate laughter or crying Causes resp failure and total paralysis No specific tests or treatment Care is supportive…may need help with ADLs Will become total care

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Cranial Nerve disorders Pg. 683 Trigeminal Neuralgia (Tic douloureux) Bell’s palsy Temporomandibular Disorder (TMD)

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Trigeminal Neuralgia (Tic douloureux) pg 683 Painful condition that involves the 5th cranial nerve—which has 3 major branches: mandibular, maxillary & ophthalmic. This sensory and motor nerve is important to chewing, facial movement, and sensation.

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Trigeminal Neuralgia (Tic douloureux) pg 683 Attacks can be initiated by slight stimulus such as cold, heat, light touch and air, vibration of music, a passing breeze, a temperature change

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Trigeminal Neuralgia The pain is described as sudden, severe, and burning It ends as quickly as it began, usually lasting a few seconds to several minutes. The cycle is repeated many times a day During a spasm, the face twitches and the eyes tear.

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Trigeminal Neuralgia Analgesics, surgery on nerve root or branches post op there is no feeling in the area corneal reflex (blinking) may be gone so need eye drops and shield

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Trigeminal Neuralgia Slightest stimulus may start attack (vibration from music, breeze, temp change they avoid washing face, shaving forehead over eyebrow is a common trigger spot so avoid touching face Do not jar the bed

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Trigeminal Neuralgia Post-op eating may be a problem as may bite tongue without knowing it food gets caught in mouth and swallowing is difficult as they lose sensation after nerve cut small sips, inspect mouth for breaks in mucus membranes

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Trigeminal Neuralgia (Tic Douloureux) Chew on opposite side Avoid hot and cold foods and use mouth rinses after eating dental appointment to check for problems as no sensations from cavity or abscess

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Trigeminal Neuralgia Dilantin and tegretol used to reduce pain as analgesics not too successful narcotics may be given Dentist should be seen as may be caused by dental deformities

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Bell’s Palsy 7th cranial nerve—responsible for movement of the facial muscles facial nerve usually affects one side

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Bell’s Palsy causes weakness and paralysis of facial muscles and eyelid facial pain, pain behind ear, numbness diminished blink reflex ptosis of eyelid, tearing of affected side

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Bell’s Palsy Speech and chewing difficulty may occur Must rule out CVA, tumor no specific test Prednisone, analgesics, electrotherapy to prevent atrophy of facial muscles most show improvement in a few weeks

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Bell’s palsy If ptosis and blinking reflex affected must wear eye patch corneal ulcerations and infection of eye may develop eye shield at night antibiotic ointment in eye eye assessment needed

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Temporomandibular Disorder pg 685 TMD is a cluster of symptoms that are localized at and about the jaw. TMD caused by arthritis of mandibular joint, malocclusion of teeth, and excessive movement of jaw at time of endotracheal intubation in general anesthsesia

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TMD S/S Jaw pain, headache, tinnitus, ear pain clenching of jaw, inability to open mouth Clicking of the jaw when the joint is moved, or the jaw can lock, which interferes with opening the mouth

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TMD S/S Pronounced spasm and tenderness of the masseter and temporalis muscles Dental x-rays help with diagnosis

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TMD Medical Management Treatment is referred to a dentist Analgesics are prescribed Custom-fitted mouth guard is worn during sleep

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TMD Medical Management TENS (transcutaneous electrical nerve stimulation), injection of a local anesthetic to relieve muscle spasm, and ice water oral irrigations are also used to reduce and relieve discomfort. Surgery is available if conservative methods are ineffective

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Extrapyramidial disorders pg 686 Parkinson’s disease Huntington’s disease One primary characteristic is abnormal movement.

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Parkinson’s Usually begins after age 50 early signs include stiffness, tremors of hands, pill rolling and difficulty performing movement Tremors decrease with voluntary movement

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Parkinson’s Intention tremor: when tremors increase during voluntary movement…may be seen in some patients Later, tremors of head, mask-like expression, stooped posture Monotonous speech and shuffling gait

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Parkinson’s Have difficulty turning or redirecting forward motion arms seldom swing while walking rigidity develops more than tremors reflexes and power of contraction are not affected but speed and movement are

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Parkinson’s Levodopa and cogentin are drugs of choice physical therapy…in extreme cases surgery done to destroy part of the thalamus so excessive muscle contraction decreased fetal tissue transplanted in brain has helped some patients

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Parkinson’s Symptoms usually begin on one side and may take 15 years to spread bilaterally late symptom is drooling and problems with swallowing eyes may roll up or down and stay in that position for days

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Huntington’s Disease pg. 689 Hereditary, degeneration of basal ganglia and cerebral cortex Causes mental apathy, emotional disturbances, choreiform movement (uncontrollable withering and twisting of body) grimacing

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Huntington’s Treatment is supportive, no cure tranquilizers and antiparkinsonian drugs to relieve choreiform movements late in the disease, may have hallucinations, delusions, impaired judgment, and becomes totally dependent

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Huntington’s 1/2 children of affected parent will develop the disease but will not find out about it until well past child bearing age must have disease to transmit trait most do not develop disease until between age 30 to 50

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Huntington’s Personality changes (obstinanacy, moodiness and lack of interest Inappropriate behavior may start before the involuntary jerky, irregular choreic movements gait is wide paced and prancing (ST. vitus dance)

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Huntington’s chorea Difficulty chewing and swallowing, speech difficulty, intellectual decline loss of bowel and bladder control severe depression may lead to suicide paranoia is common

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Nursing care extrapyramidial 43-2 pg 690 Offer fluids hourly I&O, keep suction available to prevent aspiration soft diet, allow time to chew, cut food into small bites may need to feed in later stages skin care, maintain self care as long as possible

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Nursing Care extrapyramidial Avoid stress, fatigue bowel and bladder incontinent retraining program may be helpful early, not too effective late Prone to injury, assist when ambulating or getting up…may climb over rails or wander observe frequently

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Seizure disorders pg 692 Abnormal electrical discharge of neurons can be focal or generalized idiopathic (no known cause causes---high fever, electrolyte imbalance, uremia, hypoglycemia, hypoxia, brain tumor

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Seizure disorders Epilepsy is a permanent, recurrent seizure disorder causes include brain injury at birth, head injury, metabolic disorders or idiopathic convulsive disorder and seizure disorder the same

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Seizure disorders Too much electrical discharges from nerve cells in the brain Different types: partial or focal--from a localized area, cause specific symptoms and may spread to entire brain lasts from seconds to about one minute

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Seizure disorder Jacksonian: begins at one place and spreads to another in an orderly fashion psychomotor and psychosensory: seizure with hallucinatory sights, sounds and odors mumbles and non-sense words, smacking lips

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Seizures Generalized seizure: Entire brain involved; can last several minutes, loss of consciousness absence; brief change of consciousness lasting 1 to 10 seconds, mostly children blank stare, mouth arm or eyelid movement, vacant stare, Petit mal

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Generalized seizure Myoclonic: brief involuntary muscular jerks of extremities or body Tonic-clonic: Grand mal--emotional changes, aura (seconds or minutes before), epileptic cry, loss of consciousness tonic-stiffness and rigidity

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Seizure--Grand mal Clonic phase; alternating spasms and relaxations---thrashing and jerking breathing is spasmodic frothing saliva, jaws clenched, incontinence labored breathing and cyanosis lasts 2 to 5 minutes

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Grand mal seizure Postictal stage: consciousness is regained, does not remember seizure confused, difficulty speaking, headache fatigue, soreness and may sleep for hours

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During a seizure Turn to side to keep airway patent and to prevent aspiration of saliva and vomitus suction PRN remove pillow, bedding and clothing that can obstruct breathing loosen restrictive clothing

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During a Seizure Protect from injury…do not forcibly restrain arms, legs or head stay with patient Give privacy…clear onlookers

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After a seizure Keep bed flat; turn to side until awake and responding keep room lighting dim and noise to a minimum Take vitals stat and q 30 minutes until awake inspect lips, tongue, oral cavity for injury change linen if incontinent

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Nursing Observe closely and chart activity before and after turn on side--prevent aspiration, protect from injury do not restrain, do not force objects in mouth Stay with patient take vitals after a seizure

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Nursing Assess for injury, allow to rest, report activity, time elapsed and client reaction pad side rails good mouth care--gingival hyperplasia dilantin levels give meds on schedule

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Status Epilepticus Several tonic-clonic seizures without consciousness returning this is an emergency may be from stopping seizure meds life threatening

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Medications for seizures Dilantin phenobarbital Tegretol Zarontin depakene Valium drug of choice to stop status epilepticus

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Brain Tumor pg. 697 Can result in death even if benign They take up space and block flow and absorption of CSF so cause ICP to occur headache, vomiting and papilledema is common headache usually early in AM and becomes more severe as tumor grows

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Brain tumor Projectile type vomiting without nausea, speech difficulty, double vision, paralysis Causes brain stem herniation so resp rate deeper, labored, periodic…temp usually rises but B/P stays stable

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Brain Tumor Keep as pain free as possible IV fluids and TPN may be needed--keep I&O encourage mobility as long long as possible…assist radiation & chemotherapy causes oral lesions…keep mouth moist, give sips of water

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Brain Tumor Chemotherapy, radiation and surgery used to treat craniotomy (incision thru skull) or craniectomy (part of skull removed) done, laser beams or radioisotopes inserted into tumor also done