ch59 Chronic Neurologic Problems

  1. Tension headache - site, quality, frequency, duration, time, symptoms:
    • Bilateral, bandlike pressure at base of skull and/or face
    • Constant squeezing tightness
    • Cycles over several years
    • Intermittent for months or years
    • Not related to time
    • Palpable neck and shoulder muscle stiffness, stiff neck, tenderness
  2. Migraine headache - site, quality, frequency, time, symptoms:
    • Unilateral (60%), may switch sides, commonly anterior
    • Throbbing, synchronous with pulse
    • Periodic, cycles of severaL months to years
    • Continuous for hours or days
    • May be preceded by prodrome, onset after awakening, better with sleep
    • Nausea/vomiting, edema, irritability, sweating, photophobia, phonophobia, prodrome of sensory/motor/psych phenomena, family history (in 65%)
  3. Cluster headache - site, quality, frequency, time, symptoms:
    • Unilateral, radiating up or down from one eye
    • Severe, bone-crushing
    • May have months or years between attacks, attacks occur in clusters, 1-2x/day over a period of 4-8 wks
    • 30-90 minutes
    • Nocturnal, commonly awakens patient from sleep
    • Vasomotor symptoms such as facial flushing or pallor, unilateral lacrimation, ptosis, rhinitis
  4. Triptans (e.g., sumatriptan/Imitrex, almotriptan/Axert) are the first line of therapy for prevention of migraines. What effect does triptan have on arteries? What would be a contraindication?
    • Vasoconstrict arteries
    • Contraindicated in patients with hypertension
  5. Treatment options for cluster headaches.
    • Verapamil, lithium, ergotamine, divalproex, NSAIDS
    • Inhaling 100% oxygen at 7-9 L/min x15-20 min.
    • Sumatriptan (Imitrex)
    • Methylsergode, if recurrence at a specific time
  6. Treatment options for tension headaches.
    Nonopioid analgesics (e.g., aspirin, acetaminophen) alone or with sedative, muscle relaxant, tranquilizer, or codeine.
  7. Generalized seizures:
    • Involve both sides of the brain
    • Characterized by bilateral synchronous epileptic discharges in brain from onset of seizure
    • No warning or aura
    • In most cases, loss of consciousness for a few seconds to several minutes
  8. Tonic-clonic seizures:
    • Most common generalized seizure (f.k.a. grand mal)
    • Loss of consciousness
    • Fall on ground
    • Tonic = fall to ground, stiff body for 10-20 seconds
    • Clonic = subsequent jerking phase for 30-40 seconds
    • Loss of body function control (salivation, incontinence) may occur
  9. Typical absence seizure (petit mal):
    Brief staring spell, lasts only a few seconds, often unnoticed. Usually occurs only in children, rarely beyond adolescence. EEG demonstrates 3-Hz spike-and-wave pattern unique to this type of seizure.
  10. Atypical absence seizure:
    Staring spell with other symptoms including brief warnings, peculiar behavior during seizure, or confusion after seizure. EEG demonstrates atypical spike-and-wave patterns, usually >3 Hz.
  11. Partial seizures:
    • Unilateral manifestations, localized in brain, caused by focal irritations
    • Begin in specific region of cortex
    • May be confined to one side of brain or may spread to involve entire brain, culminating in generalized tonic-clonic seizure
  12. Multiple sclerosis episodes of flair-up followed by remission are due to:
    Demyelination of nerve sheath followed by myelin regeneration.
  13. In multiple sclerosis, damage to nerve axons occurs and myelin is replaced with:
    Glial scar tissue, which forms hard, sclerotic plaques and results in slowing/blockage of nerve impulses.
  14. Medications to treat multiple sclerosis:
    • Corticosteroids - exacerbations
    • Immunomodulators - exacerbations
    • Immunosuppressants - exacerbations
    • Cholinergics - urinary retention
    • Anticholinergics - urinary frequency/urgency
    • Muscle relaxants - spasticity
    • CNS stimulants - fatigue
    • Antiviral/antiparkinsonian - fatigue
  15. Define Parkinson's disease.
    Disease of basal ganglia characterized by slowness in initiation and execution of movements (bradykinesia), increased muscle tone (rigidity), tremor at rest, and impaired postural reflexes.
  16. Parkinson's triad:
    • First sign: Tremor
    • Second sign: Rigidity
    • Third sign: Bradykinesia
  17. Parkinson's disease medication therapy:
    • Dopaminergics - enhance supply of dopamine
    • Anticholinergics - block effect of overactive cholinergic neurons
  18. Parkinson's disease first drug of choice:
    • Levodopa + carbidopa = Sinemet
    • Levodopa is chemical precursor to dopamine, crosses blood-brain barrier, converts to dopamine in basal ganglia; carbidopa inhibits enzyme dopa-decarboxylase in peripheral tissues, allowing more levodopa to get to the brain.
  19. Define myasthenia gravis.
    • An autoimmune disease in which antibodies attack acetylcholine (ACh) receptors, resulting in decreased number of ACh receptor sites on neuromuscular junctions.
    • Characterized by fluctuating weakness, with rest restoring strength and progressing weakness through the day.
  20. Myasthenic crisis r/t myasthenia gravis:
    • Acute exacerbation of muscle weakness triggered by infection, surgery, emotional distress, drug overdose, or inadequate drugs.
    • Major complications are muscle weakness with swallowing and breathing.
  21. Myasthenia gravis medication therapy:
    • Anticholinesterase drugs - enhance function at the neuromuscular junction, prolongs action of acetylcholine by inhibiting enzyme that brakes down acetylcholine; includes neostigmine (Prostigmin) and pyridostigmine (Mestinon).
    • Alternate-day corticosteroids.
    • Immunosuppressants.
  22. Cholinergic crisis r/t myasthenia gravis:
    Overdose of anticholinesterase drugs (used to treat myasthenia gravis), resulting in respiratory insufficiency and severe muscle weakness.
  23. Myasthenia gravis related crisis: Differentiating between myasthenic crisis and cholinergic crisis.
    • Administer Tensilon (anticholinesterase drug)
    • Symptoms improve = myasthenic crisis
    • Symptoms worsen = cholinergic crisis
  24. Myasthenia gravis surgical option:
    Thymus gland produces anticholinesterase; therefore, removing the thymus gland (thymectomy) results in improvement in majority of patients.
  25. Define amyotrophic lateral sclerosis (ALS).
    Progressive wasting disorder, loss of motor neurons, leads to death within 2-6 years of diagnosis. Weakness of limbs progressively moving inward until respiratory failure results in death. Patients remain cognitively intact.
  26. Nursing interventions for amyotrophic lateral sclerosis (ALS):
    • Facilitate communication
    • Reduce risk of aspiration
    • Decrease pain secondary to muscle weakness
    • Decrease risk of injury related to falls
    • Provide diversional activities such as reading and companionship
    • Help family and patient manage disease process including grieving related to loss of motor function and ultimately death
  27. Define Huntington's disease.
    Autosomal dominant (50% chance of inheritance), deficiency in acetylcholine and GABA, symptoms opposite of Parkinson's. Excessive, abnormal involuntary movements (chorea), writhing, twisting movements. Progressive disease. Death usually within 10-20 years.
  28. Care for the patient with Huntington's disease:
    • Palliative care
    • Antipsychotics (Haldol), antidepressants, and antichorea (clonazepam/Klonopin)
    • High-calorie diet (4000-5000 kCal/day)
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ch59 Chronic Neurologic Problems
Chapter 59 Chronic Neurologic Problems