Medical surgical Nursing

1. Medical surgical Nursing Caring for Clients With Neurologic and Spinal Cord Disorders Dr Ibraheem Bashayreh, RN, PhD

2. 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.

3. 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)

4. Epidemiology and course • Epilepsy usually presents in childhood or adolescence but may occur for the first time at any age.

5. Epilepsy is a symptom of numerous disorders, but in the majority of sufferers the cause remains unclear despite careful history taking,examination and investigation!

6. 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 A seizure is a symptom of epilepsy

7. The Brain Is the Source of Epilepsy • 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”

8. Epilepsy - Classification • The 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.

9. Epilepsy - Classification • Focal seizures – account for 80% of adult epilepsies • Simple partial seizures • Complex partial seizures • Partial seizures secondarilly generalised • Generalised seizures • Unclassified seizures

10. Classifying Epilepsy and Seizures • Classifying epilepsy involves more than just seizure type • Seizure types: Partial Generalized Simple Complex Absence Convulsive • Consciousness • is maintained • Consciousness • is lost or impaired • Altered awareness • Characterized by • muscle contractions • with or without loss • of consciousness

11. 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

12. 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

13. 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

14. Seizure Triggers • Missed medication (#1 reason) • Stress/anxiety • Hormonal changes • Dehydration • Lack of sleep/extreme fatigue • Photosensitivity • Drug/alcohol use; drug interactions

15. How Is Epilepsy Diagnosed? • Clinical Assessment • Patient history • Tests (blood, EEG, CT, MRI or PET scans) • Neurologic exam • ID of seizure type • Clinical evaluation to look for causes

16. Epilepsy Differential Diagnosis The 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

17. 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.

18. 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 stimulation • Lifestyle modifications

19. 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)

20. 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.

21. 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).

22. 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.

23. 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 23

24. 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.

25. Multiple Sclerosis • Pathophysiology • Autoimmune response with viral trigger • Demyelination • Spinal cord • Brain • Nerves of the CNS • Myelin replaced with plaque • Impulse transmission interrupted/ halted

26. 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

27. Multisystem effects of multiple sclerosis.

28. Multiple Sclerosis • Long-Term Consequences • Urinary tract infections • Pressure ulcers/joint contractures • Falls • Pneumonia • Depression

29. 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

30. 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

31. Multiple Sclerosis – Client Teaching • Client/Family Teaching • Triggers for exacerbations/stressors • Medications/side effects • Coping with deficits • Counseling/support groups

32. 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

33. Multiple Sclerosis – Nursing Care • Assessment • Respiratory effort • ADLs • Appearance

34. Multiple Sclerosis – Nursing Care • Nursing Diagnoses • Fatigue • Self-Care Deficit • Ineffective Coping • Impaired Mobility • Risk for Injury

35. Multiple Sclerosis – Nursing Care • Evaluation • ADL • Coping • Knowledge level • Medications • Diet • Complications

36. Parkinson’s Disease • Most common neurologic disorder in the U.S. • 1.5 million affected • Most common over age 40 • Caucasian men vs. women

37. 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

38. 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

39. Parkinson’s Disease - Medications • Medications • Dopaminergics • Dopamine agonists • Anticholinergics • MAOIs

40. 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 • Stereotacticthalamotomy: 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

41. Parkinson’s Disease – Client Teaching • Client/Family Teaching • Assistive devices • Communication techniques • Decreasing aspiration risk • Safety • Diet • Exercise

42. 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

43. Parkinson’s Disease – Nursing Care • Diagnoses • Impaired Physical Mobility • Impaired Verbal Communication • Imbalanced Nutrition: Less than Body Requirements

44. Parkinson’s Disease – Nursing Care • Evaluation • Ability to: • Ambulate • Chew and swallow • Communicate • Complications • Knowledge level related to disease process

45. Myasthenia Gravis • is an autoimmune neuromuscular disease leading to fluctuating muscle weakness and fatigability. • Women ages 20–30 • Exacerbations and remissions • Triggers for exacerbations

46. 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

47. 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

48. Myasthenia Gravis • Life-Threatening Complications • Cholinergiccrisis: 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 AChEenzyme, which normally breaks down acetylcholine • Severe muscle weakness, nausea, vomiting • Salivation, sweating, bradycardia • Myastheniacrisis: 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

49. Myasthenia Gravis - Medications • Medications • Anticholinesterase medications • Steroids • Cytotoxic agents

50. Myasthenia Gravis – Interdisciplinary Care • Short-Term Treatments • Thymectomy • Removal of the thymus • Decreased auto-antibody production • Plasmapheresis • Removes auto-antibodies