Neurological Care Plans

Chapter 7


Neurological Care Plans



Alzheimer’s Disease/Dementia


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Multi-infarct Dementia (MID); Dementia of the Alzheimer Type (DAT)


Dementia is characterized by a progressive impairment of cognitive function, personality, and behavior. The person with dementia experiences loss of memory, disorientation, impaired language skills, decreased concentration, and impaired judgment. In advanced stages, the person experiences behavior and personality changes such as aggressiveness, mood swings, wandering, and confusion. These changes interfere with the person’s ability to carry out role responsibilities and activities of daily living. The causes of dementia are numerous and include degenerative disorders of the nervous system, vascular disorders, autoimmune disorders, and traumatic brain injury such as concussions. Multi-infarct dementia develops in people who have sustained brain injury from multiple strokes. This type of irreversible dementia occurs more often in men than women. People in the later stages of acquired immunodeficiency syndrome (AIDS) may develop dementia. Alcoholism and Parkinson’s disease are known to contribute to dementia.


Alzheimer’s disease (AD) is an irreversible disease of the central nervous system that manifests as a cognitive disorder. Onset is usually between 50 and 60 years and is characterized by progressive deterioration of memory and cognitive function. Disease progression begins with memory impairment, speech and motor difficulties, disorientation of time and place, impaired judgment, memory loss, forgetfulness, and inappropriate affect, followed by loss of independence, complete disorientation, wandering, hoarding, communication difficulties, complete memory loss, and the final stage with blank expression, irritability, seizures, emaciation, and absolute dependence until death.


Although the cause is unknown, research has found specific genetic loci associated with the development of AD. Chronic inflammation, stroke, and cellular damage from free radicals have been identified as risk factors for AD. Drug therapy for AD includes cholinesterase inhibitors and n-methyl-d-aspartate (NMDA) antagonists. These drugs have been shown to delay the progression of cognitive impairment. Some patients may experience improved memory function with these drugs.


This care plan addresses needs for patients with a wide variety of dementia, of which Alzheimer’s is a type. Focus is on the home care setting.




Amyotrophic Lateral Sclerosis


Lou Gehrig’s Disease; Motor Neuron Disease; Progressive Bulbar Palsy; Progressive Muscular Atrophy


Amyotrophic lateral sclerosis (ALS), commonly called Lou Gehrig’s disease, is a rare progressive disease that attacks motor neurons, which control the movement of muscles through the anterior horns of the spinal cord and the motor nuclei of the lower brainstem. Onset is usually between 40 and 70 years of age, with men affected twice as often as women. Signs and symptoms of the disease begin with atrophic weakness of the hands and forearms in the early phase of the disease. As loss of motor neuron function progresses, the patient will develop mild lower extremity spasticity and diffuse hyperreflexia. Impaired respiratory function is present in the later phases of the disease, often requiring mechanical ventilatory support. Sensation and sphincter control are usually maintained. When the bulbar muscles are affected, dysarthria and dysphagia are seen with fasciculations in the tongue. The challenge for the patient with ALS is that awareness and cognitive function remain intact throughout the progression of the disease. There is usually progressive paralysis, with death occurring within 2 to 6 years. This care plan focuses on home care, where the patient usually remains until care needs are no longer manageable.




Carpal Tunnel Syndrome


Repetitive Stress Injury; Median Nerve Compression


Carpal tunnel syndrome develops when the median nerve is compressed as it passes through the wrist to the hand. The carpal tunnel is an anatomical canal that is located between the bones of the hand and a band of fibrous tissue. This tissue protects the tendons of the wrist during movement of the joint. Inflammation of the synovium of the joint causes swelling, pain, and paresthesia. The swelling contributes to narrowing of the tunnel and compression of the median nerve. The pain and paresthesia occurs most often in the thumb, index finger, middle finger, and radial aspect of the ring finger. Chronic median nerve compression may lead to progressive weakness and loss of fine motor control in the hand. Muscle atrophy may develop over time. This disorder has a high prevalence among people in occupations that involve repeated and prolonged flexion of the wrist. Carpal tunnel syndrome is becoming a common occupational repetitive stress injury. Other situations that are known to contribute to carpal tunnel syndrome include burn injuries of the hand, wrist fractures, rheumatoid arthritis, and diabetes mellitus. Women are more likely to develop carpal tunnel syndrome than men. This gender difference is thought to be related to the smaller size of the carpal tunnel in women. Medical management of carpal tunnel syndrome includes splinting of the joint, drug therapy to reduce inflammation and pain, and modification of activities to restrict harmful movement. Surgery is done when prolonged nerve compression is severe and associated with muscle atrophy and progressive loss of motor and sensory function.




Craniotomy


Craniectomy; Burr Hole; Cranioplasty; Cranial Surgery


Craniotomy is the surgical opening of the cranium to gain access to disease or injury affecting the brain, ventricles, or intracranial blood vessels. Craniectomy involves removal of part of the cranium to treat compound fractures, infection, or decompression. Burr holes are drilled in the cranium and used for clot evacuation and decompression of fluid beneath the dura or in preparation for craniotomy. Cranioplasty is the application of artificial material to repair the skull to improve integrity and shape. Cranial surgery is either supratentorial (above the tentorium, involving the cerebrum) or infratentorial (below the tentorium, involving the brainstem or cerebellum).




Head Trauma


Traumatic Brain Injury; Closed Trauma; Skull Fracture; Subdural Hematoma; Concussion


Head injury (craniocerebral trauma) is a leading cause of death in the United States for people 1 to 42 years of age. An estimated 3 million people suffer head injuries every year. About half of all severe head injuries result from accidents involving automobiles, motorcycles, bicycles, and pedestrians. People who do not use appropriate safety equipment (e.g., seat belts, helmets) have a significant increase in head injury with accidents. Approximately 20% of head injuries are associated with violence, such as blunt force trauma and firearms. Recent evidence identifies traumatic brain injury from concussions sustained by athletes playing contact sports and military personnel during combat. The severity of the head injury is defined by the traumatic coma data bank on the basis of the Glasgow Coma Scale (GCS): Severe head injury = GCS of 8 or less; moderate head injury = GCS of 9 to 12. Most head injuries are blunt (closed) trauma to the brain. Damage to the scalp, skull, meninges, and brain runs the gamut of skull fracture with loss of consciousness, concussion, and/or extracerebral or intracerebral pathological conditions. Patients with moderate to severe head trauma are usually observed in a critical care unit where immediate intervention can be achieved. Most deaths occur in the first few hours after head trauma as a result of internal bleeding or worsening cerebral edema. Patients with minor head trauma (scalp laceration or concussion) are most often treated and released to be observed at home with instructions to call or return if symptoms worsen. Older people are most often affected with postconcussion syndrome, characterized by decreased neurological function 2 weeks to 2 months after the initial injury and often caused by a slow subdural bleed. This care plan focuses on moderate-to-severe head trauma in the acute care setting.




Headache: Migraine, Cluster, Tension


Headache is defined as pain in the head or face, classified as either “primary” or “secondary” in origin. Migraine, cluster, and tension headaches are classified as primary because the pain occurs without a known pathological cause. Secondary headaches are a result of a known pathology, such as cranial tumor or aneurysm. Migraine headache, a recurring unilateral or bilateral headache, is the most common type of vascular headache. Multiple theories have been proposed to explain the cause of migraine headache. Evidence suggests that muscle tension, changes in cerebrovascular tone, and biochemical factors are involved in producing the pain of a migraine headache. Women are affected three times more often than men. Migraines may begin in early childhood and adolescence, and 65% of patients with migraine headaches have a family history of migraine headache. Migraines may occur with an aura or without. The aura is a collection of neurological symptoms that precede the onset of pain by 10 to 30 minutes. These symptoms include changes in level of consciousness, vision, behavior, and motor or sensory function. Many patients develop a migraine headache without a precipitating event. For other patients a variety of precipitating events trigger migraine headaches, including stress, foods high in tyramine, hunger, sleep disturbances, and for women, alterations in reproductive hormone levels. Manifestations are associated with autonomic nervous system dysfunction.


Tension headaches are the most common form of headache, occurring in women more often than men. The usual age of onset is 20 to 25 years old. The pain is usually mild to moderate and described as a tightening or sensation of pressure around the head. This type of headache is believed to be related to muscle tension in the jaw and neck with hypersensitivity of pain fibers in the trigeminal nerve. The exact mechanisms for the pain are unknown. Many patients may experience both migraine and tension headaches.


Cluster headaches are defined as pain episodes that occur for several days or weeks at a time followed by long periods of remission. The person may experience several short headaches in one day. Men are affected more often than women, with the age of occurrence between 20 and 50 years old. The pain is described as severe, with tearing, burning, and reddening of the eye on one side of the face. The mechanisms of cluster headaches are thought to be similar to those causing migraine headaches. The exact mechanisms remain unknown but may include vascular and neurogenic alterations of the hypothalamus associated with changes in serotonin transmission.


This care plan focuses on the classic migraine, which is believed to be a dysfunction of the hypothalamic and upper brainstem areas. Diagnosis, treatment, and follow-up care are usually accomplished in an outpatient setting.


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Dec 3, 2016 | Posted by in NURSING | Comments Off on Neurological Care Plans

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