Gale M. Sauer, RN FCN MSN Advance Continuing Education 2 October 2012

Transcription

1 Gale M. Sauer, RN FCN MSN Advance Continuing Education 2 October 2012

2 Controls & coordinates all systems in response to our surroundings Stimulus or change detected by our senses & interpreted by the brain Sends directions to various organs to respond & adapt

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4 The PNS is further divided into the Somatic System (SNS) & Autonomic System (ANS) The ANS is further divided into the sympathetic & parasympathetic systems Both systems provide nerve stimuli to the same organs, produce different effects

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6 May be adversely affected by smoking, lack of sleep, poor diet & stress Affected by age Neurons are lost & not replaced. Decreased capacity for transmitting impulses to & from the brain Voluntary & reflex actions become slower

7 Ghee-YAN bah-ray - RARE! Immune system attacks the myelin sheath of nerve cells outside the brain & spinal cord Muscle weakness, loss of reflexes & numbness or tingling in arms, legs, face, & other parts of the body difficulty speaking, chewing, swallowing, moving eyes Back pain

8 If weakness spreads to muscles that control breathing, heart rate, & blood pressure paralysis & death Viral or bacterial infections Campylobacter jejuni: food poisoning Mycoplasma: pneumonia Cytomegalovirus: fever, chills, sore throat, swollen glands, body aches, & fatigue Epstein-Barr: mononucleosis Varicella-zoster: chickenpox & shingles

9 When did symptoms start? How have they changed? Recent infections? Two important signs: Progressive weakening of arms & legs Loss of reflexes (automatic body movements)

10 Lumbar puncture to identify infections Nerve conduction study measures how well & how fast nerves send signals Electromyogram (EMG) measures electrical activity of muscles at rest & during contraction Referral to a neurologist

11 Immunotherapy with IVIG Addition of healthy antibodies Plasma exchange Removal of harmful antibodies Therapy may reduce severity of relapse & protect against future relapse

12 3-6 months, longer to return to baseline Long term effects Numbness in toes & fingers (common) Weakness, balance deficits (less common) Regular exercise for strengthening muscles PT OT

13 Disorder of brain's electric system Abnormal electrical impulses cause brief changes in movement, behavior, sensation, or awareness Interruptions (seizures) may last seconds or minutes People who have had two or more seizures are considered to have epilepsy

14 Convulsions or seizures Staring Falling Fumbling with clothes Several types of seizures with distinct SX

15 Often described as staring spells Person stops activity to stare vacantly for a few seconds, then continues as if nothing happened More common in children; usually starts between the ages of 4 and 12 Some children experience up to 100 absence seizures per day

16 Formerly known as grand mal seizures Usually begin with stiffening of the arms & legs, followed by jerking motions May last up to 3 minutes, after which the person may be tired & confused Related to abnormal electrical activity involving both sides of the brain

17 One side of the brain affected Simple partial seizure person is unaware of jerking movements or hallucinating Complex partial seizures, person is unaware of wandering, mumbling, smacking their lips, or fumbling with their clothes

18 Epilepsy may result from anything that disrupts the brain's natural circuitry: Severe head injury Brain infection or disease Stroke Oxygen deprivation In nearly two-thirds of people with epilepsy, a specific cause is never found (idiopathic, cryptogenic)

19 May outgrow epilepsy Regular medication may prevent seizures Precautions: Provide safe environment for children to participate in most activities

20 Very rare More likely in a person with epilepsy Most effective prevention strategy: Control seizures, especially those that occur in sleep

21 Review description of seizures, examine medical history & perform physical exam Electroencephalogram (EEG) can confirm the diagnosis & provide pertinent information Painless procedure records brain's electric activity Wave patterns change during seizure & may reveal which part of the brain is prone to seizures Results may help guide treatment

22 Most people with epilepsy live a normal lifespan rarely suffering injuries from seizures Patients prone to falls during seizures may need a special helmet Some types of seizures may increase the risk of sudden unexplained death The best way to avoid complications is to adhere to treatment that controls seizures

23 Seizures often strike without warning Losing consciousness while swimming or taking a bath could be life-threatening Extreme sports, such as mountain climbing, could be life threatening Activities should not be undertaken alone Most states require a person with epilepsy to be seizure-free for a certain time before driving a vehicle

24 Can eliminate or nearly eliminate seizures in a third of children with epilepsy Very high in fat, low in carbs the body burning fat for energy & creating ketones (fasting metabolism starvation diet) Very strict, created by a dietitian & closely monitored by medical team Recommended when medications fail or cause unacceptable side effects Children age 2 12 Children with paralysis, mental retardation

25 Sometimes called a "pacemaker for the brain Small surgically implanted device sends electrical pulses to the brain via the vagus nerve, a large nerve in the neck Another option for people who don't do well with medication

26 Half of all patients started on one anti-seizure drug remain seizure-free at least one year* About two-thirds of people with epilepsy become seizure-free by taking their medication regularly

27 In people with partial seizures, surgery may offer a cure If the medical team determines the seizures consistently begin in a single area of the brain they remove the area Removal may stop the seizures or make them easier to manage with medication May be done to treat underlying conditions such as a brain tumor

28 Less than 1% of patients who fail to respond to anti-seizure medications achieve adequate control on subsequent drug trials These medication resistant patients should be considered for surgery or other non-drug treatments sooner rather than later

29 Detailed images of the brain from CT or MRI scans can help doctors rule out tumors or blood clots as a possible cause of seizures This information is essential in planning surgery to treat epilepsy

30 Prolonged or recurring seizures are called status epilepticus serious complications requiring emergency treatment IV medications Supplemental oxygen

31 More than 90% of babies born to women with epilepsy are healthy Consult a doctor before getting pregnant It may be necessary to adjust medication Some drugs appear to be less risky during pregnancy than others

32 Some dogs appear to sense a person's seizure before it begins, providing an early warning system in which a person may be able to move to safety Many dogs can be trained to react to a seizure Lying next to the person to help prevent injury Alerting caregivers to seizure onset

33 Pursue two important goals To increase the number of people who can fully control their seizures To reduce the side effects of treatment Implantable devices that could alert patients prior to seizure onset

34 Brain disorder gradual loss of muscle control SX tend to be mild at first & overlooked Distinctive SX include tremors, stiffness, slowed body movements & poor balance Parkinson's was originally called "shaking palsy but not everyone has a tremor

35 Life expectancy is about the same SX may evolve slowly over 20 years Early treatment can provide SX free YEARS! About 5% to 10% of cases occur before age 50 Two advocates for research developed PD early: Boxer Muhammad Ali at age 42 Actor Michael J. Fox at age 30

36 Slight shaking of a finger, hand, leg, or lip Stiffness or difficulty walking Difficulty getting out of a chair Small, crowded handwriting Stooped posture A 'masked' face, frozen in a serious expression

37 Early symptom -70% of people with disease Usually in a finger or hand at rest Rhythmic - four to six beats per second Pill-rolling between the thumb & index finger Tremor may be a symptom of other conditions not a defining symptom

38 Vs. slowing of movement related to age A slowness of movement may impair daily life The body may not respond right away to an effort to move, or may suddenly stop or "freeze" Shuffling walk & "mask-like" face

39 Stooped posture Drooping shoulders Head jutted forward Poor balance increases the risk of falling

40 Muscles stay stiff & don't relax Arms may not swing when walking May cause cramping or pain in the muscles Most people with PD experience some rigidity

41 Restless sleep or daytime fatigue A soft voice or slurred speech Difficulty swallowing Memory problems, confusion, or dementia Oily skin and dandruff Constipation

42 Tap your finger & thumb together or tap your foot to check for slowed movement Rest your hand to observe your tremor HCP will manipulate neck, arms, & legs to check for rigidity While standing, HCP will gently pull from behind to check for balance

43 A tremor, but no other Parkinson s-like symptoms, may be benign essential tremor Runs in families, much more common Usually affects both hands equally & is worse with motion Does not respond to levodopa, but may be treated with other medications

44 Average age of onset is 62 Still only a 2% to 4% likelihood of developing the disease > 60 Having a family member with PD slightly increases risk Men are one-and-a-half times more likely to have PD than women

45 Substantia nigra (brain stem) Controls movement Produces dopamine Helps nerve cells communicate Dopamine production stops in PD

46 Progressive, changes continue in brain over time HCP measures the stages of PD by assessing SX Hoehn & Yahr Scale looks at severity Unified Parkinson Disease Rating Scale evaluates mental clarity & function, behavior & mood, activities of daily living, & motor functions Staging can help determine the best treatment

47 Levodopa (L-dopa) is an amino acid that the brain converts into dopamine; Used since the 1970s Remains the most effective medication Reducing bradykinesia & rigidity Eventually, levodopa may wear off quickly It should not be taken with a high-protein diet Common side effects: nausea, vomiting & drowsiness Hallucinations, paranoia & involuntary movements (dyskinesias) may occur with longterm use

48 Mimic dopamine, may delay movementrelated symptoms Apokyn, Mirapex, Parlodel, & Requip Apokyn - an injectable rescue medication Used when levodopa begin to wear off or occasional episodes of immobility Usually effective within 10 mins. for mins. Side effects may include nausea, vomiting, drowsiness, fluid retention & psychosis No Alcohol!

49 In early stages of PD use may allow treatment with levodopa to be delayed Dopamine agonists have more side effects & don't control symptoms as well as levodopa Long term motor complications tend to occur no matter what medicine is used first Whether to use levodopa or dopamine agonists as the first treatment has not been fully resolved. TX choice will differ between patients.

50 Comtan & Tasmar can improve effectiveness of levodopa, with a possible side effect of diarrhea TX with Tasmar requires liver function monitoring Stalevo combines levodopa, carbidopa & entacapone (the drug in Comtan) Azilect, Eldepryl & Zelapar, which inhibit the breakdown of dopamine, may be prescribed early in PD or used with levodopa They should not be used with certain antidepressants

51 Electrodes implanted in globus pallidus, thalamus, or subthalamic nucleus A pulse generator goes in the chest near the collarbone Electric pulses stimulate the brain to help reduce rigidity, tremors & bradykinesia Doesn t stop progression of PD or affect other symptoms Not everyone is a good candidate

52 Radio-frequency energy used to permanently destroy a pea-sized area in the globus pallidus or thalamus These areas associated with tremor, rigidity & bradykinesia, so surgery less reliance on levodopa However, surgeries are irreversible & less common than deep brain stimulation

53 Specially trained dogs can Pick up dropped items or fetch requested ones Provide balance support Open and close doors, turn lights on Sense when someone is "freezing" & touch the foot to let the person keep walking Groups like the Delta Society can help you find a good service dog

54 Calcium & vitamin D for bone strength Although protein can interfere with levodopa, medication can be taken prior to meals TX nausea with crackers, ginger ale or ginger beer A high-fiber diet & adequate fluid can prevent constipation

55 Researchers are investigating supplements & other substances that may protect neurons from PD damage Coffee drinkers & smokers may have a lower risk of developing Parkinson's (although smoking obviously has other serious health consequences)

56 Studies indicate that exposure to pesticides and herbicides may increase the risk of PD Some people may be more susceptible genetically to environmental exposures Research in this area continues

57 Exercise may have a protective effect by enabling the brain to use dopamine more effectively Improves coordination, balance, gait & tremor For the best effect, exercise should be consistent & intense, preferably 3-4 times a week for an hour Working out on a treadmill or biking have been shown to have a benefit Tai chi and yoga may help with balance and flexibility

58 Medication: mood disorders, such as depression and anxiety Occupational therapist: home safety evaluation Remove fall hazards (throw rugs, power cords) Add grab bars in the bathroom Speech therapist: Swallowing and speech problems

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60 Immune system attacks the myelin (fatty tissue surrounding the nerve fibers in the brain, spinal cord, and optic nerves) Myelin insulates the nerves and helps them send electrical signals that control movement speech, and other functions Destruction scar tissue (plaques or lesions -patches of demyelination) Nerve messages are not transmitted properly

61 Medical history and neurological exam More than 90% of people with MS have scar tissue that shows up on an MRI (CT scan to a lesser extent) Spinal fluid reveals abnormalities in the brain and spinal cord Electrical activity is measured Lab tests rule out other autoimmune conditions or infections such as HIV or Lyme disease

62 The most common early symptoms of MS include: Tingling Numbness Loss of balance Weakness in one or more limbs Blurred or double vision

63 Less common symptoms of MS may include: Slurred speech Sudden onset of paralysis Lack of coordination Cognitive difficulties With progression, other symptoms may include muscle spasms, sensitivity to heat, fatigue, changes in thinking or perception, and sexual disturbances

64 Relapsing/Remitting (RRMS) characterized by : Exacerbations (or relapses) during which new SX may appear & old ones resurface or worsen Relapses can last for days, weeks or months Remission, during which the person fully or partially recovers from the deficits acquired during the relapse Recovery can be slow & gradual or almost instantaneous The vast majority of people presenting with Multiple Sclerosis are first diagnosed with relapsing/remitting Typically when they are in their twenties or thirties Twice as many women as men present with this variety

65 Secondary Progressive (SPMS): Many people with RRMS will pass into a secondary progressive phase characterized by gradual worsening of SX between relapses In Secondary Progressive, the person with MS (PwMS) may experience few relapses that merge into a general progression PwSPMS may experience good & bad days or weeks, but no real recovery After 10 years, 50% of PwRRMS will develop SPMS By 25 to 30 years, that figure will have risen to 90%

66 Fatigue - characteristic and common in the mid-afternoon May present with increased muscle weakness, mental fatigue, sleepiness, or drowsiness Physical exhaustion is not related to the amount of work performed PwMS complain of extreme fatigue even after a good night's sleep Heat sensitivity - Heat sensitivity (appearance or worsening of symptoms) occurs in most PwMS

67 Spasticity - common and often debilitating Usually affects legs and arms May interfere with ability to move muscles freely Dizziness* common to feel "off balance" or lightheaded Vertigo* (surroundings are spinning) - less common *These symptoms are caused by damage in the nerve pathways coordinating vision and other inputs into the brain that are needed to maintain balance

68 Impaired thinking - occurs in about half of PwMS (slowed thinking, decreased concentration, or decreased memory Approximately 10% of PwMS have severe impairment impacting their ability to carry out ADL Vision problems - relatively common in PwMS Optic neuritis, occurs in 55% of PwMS blurring or graying of vision or blindness in one eye Most vision problems do not lead to blindness

69 Abnormal sensations common "pins and needles, numbness, itching, burning, stabbing, or tearing pains. Not life-threatening or debilitating and can be managed or treated Speech and swallowing problems common Often associated with speech problems

70 Tremors - Fairly common May be debilitating and difficult to treat Difficulty walking very common Related to muscle weakness and/or spasticity, or balance problems, numbness feet Rare symptoms include breathing problems and seizures

71 Research suggests that: Disease may be more active during the summer months Heat and high humidity may temporarily worsen symptoms Very cold temperatures and sudden changes in temperature may aggravate symptoms

72 A direct result of the demyelination process impaired transmission of electrical signals to muscles and the organs The symptoms include: weakness, tremors, tingling, numbness, loss of balance, vision impairment, paralysis, and bladder or bowel problems Medication, rehabilitation, and other treatments to control many of these symptoms

73 Paralysis (a primary symptom) pressure ulcers Urinary incontinence frequent UTIs Ideal goal is to avoid secondary symptoms by treating primary symptoms

74 Social, psychological, and vocational complications associated with the primary and secondary symptoms Depression - common

75 Demyelination (deterioration of the protective sheath that surrounds nerve fibers) can occur in any part of the brain or spinal cord Demyelination in the nerves that send messages to the muscles causes problems with movement (motor symptoms) Demyelination along the nerves that carry sensory messages to the brain causes disturbances in sensation

76 MS follows a varied and unpredictable course starting sometimes with a single SX, followed by months or years without any progression or SX becomes worse within weeks or months Although a wide range of SX can occur, a given individual may experience only some and never others SX may occur once, resolve, and never return Not useful to compare PwMS to one another

77 While there is no cure for MS, there are "disease-modifying drugs" that can Reduce the frequency and severity of attacks Decrease damage to the brain and spinal cord over time, slowing the progression of disability High-dose corticosteroids can cut short an exacerbation Many medications manage symptoms (muscle spasms, incontinence, and pain)

78 50% PwMS develop pain as a result of damage to nervous system, muscle spasms or strain Antidepressants and anticonvulsant medications may ease nerve pain. Analgesics and antispasmodics Massage and physical therapy

79 PwMS can learn to compensate for decreased balance, coordination, or muscle strength Physical therapy strengthens muscles, combats stiffness, and increases mobility Occupational therapy increases hand coordination allowing independence in ADLs A speech therapist assists with speaking or swallowing difficulties

80 Many nontraditional therapies for MS have not been well studied Acupuncture may relieve muscle spasms and pain, but research isn't conclusive Bee venom injections showed no improvements in disability, fatigue, or the number of MS attacks in a rigorous study lasting 24 weeks

81 Doctors generally agree that it s safe for women with MS to get pregnant Research suggests no increased risk of complications during pregnancy Many women have fewer symptoms during pregnancy High levels of hormones and proteins may suppress the immune system, reducing the odds of a new attack Some drugs should not be used while pregnant/nursing In the early months after delivery, the odds of relapse can rise

82 ow-epilepsy-overview, retrieved 11 June retrieved 11 June retrieved 11 June retrieved 11 June 2012.

83 retrieved 11 June retrieved 12 June /, retrieved 12 June 2012.

84 retrieved 12 June %93Barr%C3%A9_syndrome, retrieved 12 July 2012.