1 Adult Health II Neurological Diseases Jerry Carley RN, MSN, MA, CNE Summer, 2010

Concept Map: Selected Topics in Neurological Nursing PATHOPHYSIOLOGY Traumatic Brain Injury Spinal Cord Injury Specific Disease Entities: Amyotropic Lateral Sclerosis Multiple Sclerosis Huntington’s Disease Alzheimer’s Disease Huntington’s Disease Myasthenia Gravis Guillian-Barre’ Syndrome Meningitis Parkinson’s Disease PHARMACOLOGY --Decrease ICP --Disease / Condition Specific Meds ASSESSMENT Physical Assessment Inspection Palpation Percussion Auscultation ICP Monitoring “Neuro Checks” Lab Monitoring Diagnostic Testing Care Planning Plan for client adl’s, Monitoring, med admin., Patient education, more…based On Nursing Process: A_D O_P_I_E Nursing Interventions & Evaluation Execute the care plan, evaluate for Efficacy, revise as necessary A-D-O-P-I-E

 Progressive  Grossly affects motor function  Symptoms of Parkinson's disease may appear at any age, but the average age of onset is 60  Rare in people younger than 30, but 5% - 10% of pts experience symptoms before the age of 40 3

 Normally Dopamine & Ach neurotransmitters work together to enable motor neurons to refine voluntary movement  Parkinson's results from the degeneration of dopamine-producing nerve cells in the brain, specifically in the substantia nigra and locus coeruleus  Clients have lost 80% or more of their dopamine-producing cells by the time symptoms appear 4

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1)Tremors (at rest) 2)Muscle Rigidity (may produce muscle pain, expressionless, mask-like face, difficulty chewing) 3)Bradykinesia (slow movement) 4)Cognitive impairment (mood swings…dementia) 5)Postural instability: - Falls are common - Poor balance - Stooped posture - Difficulty walking (slow, shuffling, propulsive gait) 8

 Based on symptoms and ruling out other disorders that produce similar symptoms  Must have two or more of the primary symptoms, one of which is a resting tremor or bradykinesia  Often diagnosis is made after observing that symptoms have developed and become established over a period of time 9

 There is no cure for Parkinson's disease  Treatment centers on relieving symptoms  meds  surgery or surgically implanted device that lessens tremors 10

Dopamine Replacement / Agonists  Levodopa (DOPAR) - can become ineffective over time - abnormal movements (dyskinesias)  Levodopa and carbidopa combined (Sinemet®) is the mainstay of Parkinson's therapy  Side effects: gastrointestinal distress, especially early in treatment, hypotension, and dyskinesias  Slow dosage adjustment and taking medication with food can reduce these effects and using lowest effective dose may prevent or delay appearance of motor dysfunction 11

Dopamine Agonists  Parlodel  Mirapex (pramipexole)  Side effects: hypotension and hallucinations 12

13  Dopamine Agonists Dopamine agonists mimic dopamine's function in the brain. They are used primarily as adjuncts to levodopa/carbidopa therapy. They can be used as monotherapy but are generally less effective in controlling symptoms with Side effects similar to those produced by levodopa - Bromocriptine (Parlodel®) - Pergolide (Permax®) - Pramipexole (Mirapex®) - Ropinirole (Requip®)  MAO-B Inhibitors Dopamine is oxidized by monoamine oxidase B (MAO-B). Selegiline (Carbex®) inhibits MAO-B, increasing the amount of available dopamine in the brain. MAO-B inhibitors boost the effects of levodopa  Anticholinergics reduce the relative overactivity of the neurotransmitter acetylcholine to balance the diminished dopamine activity. This class of drugs is most effective in the control of tremor, and they are used as adjuncts to levodopa. Side effects associated with anticholinergic drugs include dry mouth, blurred vision, constipation, and urinary retention - Benztropine mesylate (Cogentine®) - Biperiden (Akineton®) - Diphenhydramine (Benadryl®) - Trihyxyphenidyl (Artane®)  COMT (catechol-O-methyl transferase) Inhibitors These new class of Parkinson's medications augment levodopa therapy by inhibiting the COMT enzyme, which metabolizes levodopa before it reaches the brain. Inhibiting COMT increases the amount of levodopa that enters the brain. These drugs are only effective when used with levodopa - Entacapone (Comtan®) - Tolcapone (Tasmar®)

 It is imperative that patients inform their physician of any over-the-counter medications, herbs, or other supplements that they use on a regular basis, because they may interact with medication and because drug dosages may need to be adjusted 14

 Surgery may control symptoms and improve quality of life when medication ceases to be effective or when medication side effects, such as jerking and dyskinesias, become intolerable  Only about 10% of Parkinson's patients are estimated to be suitable candidates 15

16 Ablative Surgery - This procedure locates, targets, and then destroys (ablates) a clearly defined area of the brain affected by Parkinson's - The object is to destroy tissue that produces abnormal chemical or electrical impulses that produce tremors and dyskinesias - This type of surgery involves either pallidotomy or thalamotomy - A related procedure, cryothalamotomy, uses a supercooled probe that is inserted into the thalamus to freeze and destroy areas that produce tremors Deep Brain Stimulation (DBS) - DBS targets the subthalamic nucleus, which is located below the thalamus and is difficult to reach, the globus pallidus, or the thalamus - Targeted region is inactivated, not destroyed, by an implanted electrode Transplantation or Restorative Surgery - In transplantation, or restorative, surgery dopamine-producing cells are implanted into the striatum - The cells used for transplantation may come from one of several sources: the patient's body, human embryos, pig embryos

 Goal = help relieve symptoms & improve quality of life  Physical therapy can help strengthen and tone underused muscles, and give rigid muscles a better range of motion. The goal is to help build body strength, improve balance, overcome gait problems, and improve speaking and swallowing  Simple physical activity such as walking, gardening, and swimming can improves one's sense of well-being  Gentle, soothing massage techniques may provide relief from muscle rigidity and may have some neuromuscular benefit as well  The slow flowing movements of Tai Chi help maintain flexibility, balance, and relaxation  Support groups provide a caring supportive environment in which patients and their loved ones can ask questions about Parkinson's, expressing their frustrations, and obtain advice about coping with and treating symptoms from people who share the same problem  Parkinson's appears to progress more slowly in those who remain involved in activities that they enjoyed before the onset of symptoms and in those who engage in new interests 17