Neurologic-and-Spinal-Cord-Disorders-(神经和脊髓疾病的护理)-.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,4/1/2011,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,4/1/2011,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,4/1/2011,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,4/1/2011,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,4/1/2011,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,4/1/2011,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,4/1/2011,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,4/1/2011,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,4/1/2011,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,4/1/2011,*,EPILEPSY,D,EFINITION,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.,4/1/2011,1,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),4/1/2011,2,EPIDEMIOLOGY AND COURSE,Epilepsy usually presents in childhood or adolescence but may occur for the first time at any age.,4/1/2011,3,THE BRAIN IS THE SOURCE OF EPILEPSY,6,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”,4/1/2011,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,.,4/1/2011,7,EPILEPSY-CLASSIFICATION,Focal seizures,account for 80%of adult epilepsies,Simple partial seizures,Complex partial seizures,Partial seizures secondarilly generalised,Generalised seizures,Unclassified seizures,4/1/2011,8,CLASSIFYING EPILEPSY AND SEIZURES,Classifying epilepsy involves more than just,seizure type,Seizure types:,Partial,Generalized,SimpleComplexAbsenceConvulsive,9,Consciousness,is maintained,Consciousness,is lost or impaired,Altered awareness,Characterized by,muscle contractions,with or without loss,of consciousness,4/1/2011,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,Alzheimers disease,Stroke,Autism,10,4/1/2011,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,11,4/1/2011,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,12,4/1/2011,SEIZURE TRIGGERS,Missed medication(#1 reason),Stress/anxiety,Hormonal changes,Dehydration,Lack of sleep/extreme fatigue,Photosensitivity,Drug/alcohol use;drug interactions,13,4/1/2011,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,14,4/1/2011,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,4/1/2011,15,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,.,4/1/2011,16,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,17,4/1/2011,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),4/1/2011,18,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.,4/1/2011,19,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).,4/1/2011,20,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.,4/1/2011,21,POTENTIALLY DANGEROUS RESPONSES TO SEIZURE,DO NOT,Put anything in the persons 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,22,4/1/2011,22,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:2040,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,PARKINSONS DISEASE,Most common neurologic disorder in the U.S.,1.5 million affected,Most common over age 40,Caucasian men vs.women,PARKINSONS DISEASE,Pathophysiology,Deficiency of dopamine,Atrophy of cerebral cortex neurons,Decreased dopamine receptors,Loss of inhibition of acetylcholine,Constant excitement of motor neurons,PARKINSONS DISEASE,Manifestations of Parkinsons,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,PARKINSONS DISEASE-MEDICATIONS,Medications,Dopaminergics,Dopamine agonists,Anticholinergics,MAOIs,PARKINSONS 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,Parkinsons Disease,(PD),where a selected portion of the,thalamus,is surgically destroyed(ablated).,Deep brain electrical stimulation,Complementary therapy,Yoga,Massage,Acupuncture,PARKINSONS DISEASE CLIENT TEACHING,Client/Family Teaching,Assistive devices,Communication techniques,Decreasing aspiration risk,Safety,Diet,Exercise,PARKINSONS 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,PARKINSONS DISEASE NURSING CARE,Diagnoses,Impaired Physical Mobility,Impaired Verbal Communication,Imbalanced Nutrition:Less than Body Requirements,PARKINSONS 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 2030,Exacerbations and remissions,Triggers for exacerbation,s,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